Abstract

Introduction: Comprehensive documentation on initial patient assessments is critical in ensuring high-quality patient care and preventing communication lapses among the providers. Inaccurate or incomplete documentation has been associated with medication mistakes and adverse patient outcomes. Identification of the causes of non-compliance with documentation is important for providing focused interventions. Methodology: This research used a descriptive cross-sectional design in evaluating the completeness of initial patient assessment documentation by Resident Medical Officers (RMOs). Data was collected from 400 purposively sampled inpatient records from different departments of the hospital. Results: The most common obstacles are poor training, absence of standardized procedures, and unfavorable patient-to-staff ratios. Resolving these problems by introducing formal training schemes and the utilization of electronic health records has been found to enhance documentation processes. Classifying causes under Man, Machine, Method, and Material (4M) facilitated visualizing how human resource shortages, process inefficiencies, and infrastructural lags all cumulatively led to documentation delay and non-compliance. Conclusion: Clinical documentation, especially new patient assessment, plays a crucial role in hospital operations, patient safety, and quality of care. Yet it is often underappreciated and periodically done, posing clinical, legal, and operational hazards. Based on best practices, the research highly suggests the adoption of an EMR system with organized templates and real- time notifications to enhance compliance, minimize errors, and improve data security and also quality of care.

• 1.   Abd El Rahman, A. I., Ibrahim, M. M., & Diab, G. M. (2021). Quality of Nursing Documentation and its Effect on Continuity of patients’ care. Menoufia Nursing Journal, 6(2), 1-18.
• 2.   Aulia, K. R., Girsang, E., & Nasution, S. W. (2022). Analysis Of The Completeness Of Filling In Inpatient Medical Records In Putri Hijau Hospitals Medan. International Journal of Health and Pharmaceutical (IJHP), 2(4), 660-668.
• 3.   Bunting, J., & de Klerk, M. (2022). Strategies to improve compliance with clinical nursing documentation guidelines in the acute hospital setting: A systematic review and analysis. SAGE Open Nursing, 8, 23779608221075165.
• 4.   Daly, C., Callanan, I., & Butler, M. (2013). Safety comes first: are doctors attentive enough to their initial clinical assessment notes?.
• 5.   Demsash, A. W., Kassie, S. Y., Dubale, A. T., Chereka, A. A., Ngusie, H. S., Hunde, M. K., ... & Walle, A. D. (2023). Health professionals’ routine practice documentation and its associated factors in a resource-limited setting: a cross-sectional study. BMJ health & care informatics, 30(1), e100699.
• 6.   Ebbers, T., Kool, R. B., Smeele, L. E., Dirven, R., den Besten, C. A., Karssemakers, L. H., ... & Takes, R. P. (2022). The impact of structured and standardized documentation on documentation quality; a multicenter, retrospective study. Journal of Medical Systems, 46(7), 46.
• 7.   Erickson, M., Erickson, M. L., McKnight, R., & Utzman, R. (2008). Physical therapy documentation: from examination to outcome. Slack Incorporated.
• 8.   Esper, P., & Walker, S. (2015). Improving documentation of quality measures in the electronic health record. Journal of the American Association of Nurse Practitioners, 27(6), 308-312.
• 9.   Fajariani, V., Noor, N. B., & Amqam, H. (2020). Completeness analysis of completeness filling and time of returning the medical record for inpatient patients at Regional General Hospital of Makassar City. Journal of Asian Multicultural Research for Medical and Health Science Study, 1(2), 74-83.
• 10.   Fatima, N., Anwar, N., Mujtaba, H. U., & Shamsi, T. (2021). Compliance of documentation by health-care professionals: Evaluation of transfusion practices at bedside. Global Journal of Transfusion Medicine, 6(2), 183-188.
• 11.   Green, G., & Aframian, A. (2014). Ward round documentation in a major trauma centre: can we improve patient safety?. BMJ Quality Improvement Reports, 3(1).
• 12.   Gudmundsen, A. C., Norbye, B., Dahlgren, M. A., & Obstfelder, A. (2020). Interprofessional student groups using patient documentation to facilitate interprofessional collaboration in clinical practice–A field study. Nurse Education Today, 95, 104606.
• 13.   Ibrahim, M. M. (2023). The Effect of Completeness of Filling Out Important Reports on Delay in Return of Medical Record Files. Consilium Sanitatis: Journal of Health Science and Policy, 1(3), 188-201.
• 14.   Indarti, C. (2022). Analysis of Medical Record Document Filling Completeness of Outpatient at Nala Husada Dental Hospital. Insisiva Dental Journal: Majalah Kedokteran Gigi Insisiva.
• 15.   Khan, M. A., Nilima, N., Prathibha, J., Tiwary, B., & Singh, M. (2020). Documentation compliance of in-patient files: a cross sectional study from an east India state. Clinical Epidemiology and Global Health, 8(4), 994-997.
• 16.   Mallawarachchi, S. M. N. S. M. (2022). Clinical Documentation Practice: A Study of Doctors’ Medical Documentary Compliance in Government Hospitals in Gampaha District, Sri Lanka. Hospital Topics, 100(3), 105-111.
• 17.   McCabe, M. E., Mink, R., Turner, D. A., Boyer, D. L., Tcharmtchi, M. H., Werner, J., ... & Mason, K. E. (2022). Best practices in medical documentation: a curricular module. Academic Pediatrics, 22(8), 1271-1277.
• 18.   McLiesh, P., Rasmussen, P., & Wiechula, R. (2023). Do contemporary patient assessment requirements align with expert nursing practice?. The Australian Journal of Advanced Nursing, 40(3), 28-35.
• 19.   Medis, F. A. A. R., & untuk Diisi, P. (2022). Initial Assessment Form of Medical Record Document: Is It Important to Complete?. Jurnal Kedokteran Brawijaya, 32(1), 19-25.
• 20.   Moy, A. J., Schwartz, J. M., Chen, R., Sadri, S., Lucas, E., Cato, K. D., & Rossetti, S. C. (2021). Measurement of clinical documentation burden among physicians and nurses using electronic health records: a scoping review. Journal of the American Medical Informatics Association, 28(5), 998-1008.
• 21.   Pau, A. K., Morgan, J. E., & Terlingo, A. (1989). Drug allergy documentation by physicians, nurses, and medical students. American Journal of Health-System Pharmacy, 46(3), 570-573.
• 22.   Perry, J. J., Sutherland, J., Symington, C., Dorland, K., Mansour, M., & Stiell, I. G. (2014). Assessment of the impact on time to complete medical record using an electronic medical record versus a paper record on emergency department patients: a study. Emergency Medicine Journal, 31(12), 980-985.
• 23.   Porcuna-Enguix, L., Bustos-Contell, E., Serrano-Madrid, J., & Labatut-Serer, G. (2021). Constructing the audit risk assessment by the audit team leader when planning: using fuzzy theory. Mathematics, 9(23), 3065.
• 24.   Rahmatiqa, C., Abdillah, N., & Yuniko, F. (2020). Factors that cause compliance filling medical records in hospitals. International Journal of Community Medicine and Public Health, 7(10), 4180.
• 25.   Samad, A., Naz, F., Butt, N. I., Ashraf, Z., Ghoauri, M. S. A., & Naveed, R. M. (2024). Clinical Audit on Accuracy and Timeliness of Patient Admission Notes to Improve Quality of Care at a Tertiary Care Hospital. Pakistan Journal of Public Health, 14(2), 99-102.
• 26.   Steel, J., Georgiou, A., Balandin, S., Hill, S., Worrall, L., & Hemsley, B. (2019). A content analysis of documentation on communication disability in hospital progress notes: diagnosis, function, and patient safety. Clinical Rehabilitation, 33(5), 943-956.
• 27.   Supriadi, N. D., & Dewi, N. (2019, October). Factors causing incomplete filling of medical records of inpatients in private hospitals X tangerang city. In AIPHC 2019: Proceedings of the Third Andalas International Public Health Conference, AIPHC 2019, 10-11th October 2019, Padang, West Sumatera, Indonesia (p. 256). European Alliance for Innovation.
• 28.   Syukria, O. A., & Wardhani, V. (2022). Completeness of Medical Record Documents: Exploration on Causes and Solutions. Jurnal Kedokteran Brawijaya.
• 29.   Tariq, R. A., Vashisht, R., Sinha, A., & Scherbak, Y. (2018). Medication dispensing errors and prevention.
• 30.   Tate, K., Ma, R., Reid, R. C., McLane, P., Waywitka, J., Cummings, G. E., & Cummings, G. G. (2023). A first look at consistency of documentation across care settings during emergency transitions of long-term care residents. BMC geriatrics, 23(1), 17.
• 31.   Thierer, T. E., & Delander, K. A. (2017). Improving documentation, compliance, and approvals in an electronic dental record at a US dental school. Journal of dental education, 81(4), 442-449.
• 32.   Tola, K., Abebe, H., Gebremariam, Y., & Jikamo, B. (2017). Improving completeness of inpatient medical records in Menelik II referral hospital, Addis Ababa, Ethiopia. Advances in Public Health, 2017(1), 8389414.
• 33.   Tollinche, L. E., Shi, R., Hannum, M., McCormick, P., Thorne, A., Tan, K. S., ... & Yeoh, C. (2020). The impact of real-time clinical alerts on the compliance of anesthesia documentation: a retrospective observational study. Computer methods and programs in biomedicine, 191, 105399.

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