Background: One of the purposes of the medical record is to ensure documentation of compliance with institutional, professional and governmental regulations in order to achieve a standard that would reflect patient`s care. We hypothesized that completeness of the medical record may contribute to improving neonatal care. Currently, the medical and nursing records in our NICU are hand written, and only medical records, admission notes and discharge letters are computerized.
Objective: To evaluate the quality of the medical record in the NICU and to increase assimilation of standard medical and nursing recording practices as an initial step to improve quality of care.
Methods: A questionnaire composed of items that specify health measures was developed based on the Israel Health Ministry and the Joint Commission International (JCI) requirements. Adopted items (186) were separated to medical, nursing and secretarial sections. A neonatologist, a nurse and the unit secretary review each month medical records for the existence and documentation of the selected items. A computerized analysis is performed and results are received for further feedback.
Results: The main medical unsatisfied issues were related to inappropriate documentation of conversations with parents, documentation of consultants, and orders which were not medications, such as phototherapy or ventilation parameters. In the nursing section, documentation of parental guidance for breast milk pumping, lactation, skin to skin contact, prevention of infection and resuscitation was steadily increasing. The discharge program was not fully completed. The secretarial section missed a discharge letter sent to the pediatrician.
Conclusion: The project is dynamic and allows elimination and addition items according the results. Suboptimal findings, that pinpoint weak practices, can be flagged and corrected within a reasonable time. The project enables to set priorities for future activities and it serves as a springboard to a fully computerized NICU. Following assimilation we will re-evaluate its impact on neonatal quality health measures.
