Background: Improving medical record completeness services is an important step towards improving the quality of healthcare. It can also provide valuable information to help measure progress and effectiveness of involved service provided. The medical record has become an important legal document; good medical records “in terms of completeness and accuracy of recorded information “are essential not only for the present and future care of the patient but also as a legal document to protect the patient and the hospitals from litigation. Many studies have been carried out to assess the completeness of family health records; but this data must be checked regarding its accuracy. the current study will determine to what extent the recorded data represent the true situation by interviewing the patients at the selected family health center. The current study will focus on family forms specific for the most prevalent chronic diseases among adults in Egypt Hypertensive and Diabetic patients as evidenced by the latest Demographic and Health Survey, 2017.
Aim of the Study: To measure the completeness and accuracy of the family health record forms specific for diabetic and hypertensive patient. Design: descriptive Cross-sectional study. Patients & Methods: A convenient sample of 200 fully functioning files for Hypertensive & Diabetic Patients were included in the study. The study was conducted at an accredited center (Meet Okba family health center, Giza Governorate Feb,2019).Two Study Tools were used; first one for checking the Completeness of Family Records through medical record assessment checklist, second one for checking the accuracy of Family Records through Interview questionnaire to Hypertensive and Diabetic Patients whose fully functioning files(200 files) were selected to be included in the study sample. Results: Regarding completeness; 76%, 57% and 34% of the personal data form, investigation form and clinical exam sheets respectively showed completeness more than 80% (according to standard scoring level).Regarding accuracy; inaccurate results were found as (73,5%, 63,4.0%and 90%) of the follow up of diabetic-hypertensive patient, investigation and clinical exam sheets respectively. the least item to be accurate and complete in personal data form was the social, behavior hist.,(8.5%), Most of the recorded clinical examination items (e.g. Color and temp of foot, head and neck examination, reflexes & signs of fungus infection) were almost recorded complete but inaccurate ranging from (82.5-83.0%); Conclusion: To improve the quality of Medical Record we need regular auditing, training and good orientation of medical personnel for accurate record practices.