Audit of Diabetics’ Medical Records in a Primary Health Care Center,HASSAN AL-MUSA
Abstract
Objective: To assess the diabetic patients' medical records as regard the quality of their data and the level of the patients' disease control achieved.
Methodology: This study follows a cross sectional study design. The sampling frame comprised all medical records for diabetic patients registered at Al-Manhal PHCC. Following a simple random sample technique, 223 medical records for registered diabetic patients were assessed. Collected data were entered into the computer using the professional statistical package for social sciences (SPSS, version 13.0).
Results: Regarding auditing of the personal data, the quality of life was not found in all file. Regarding disease information, the disease severity was recorded for only 6 patients. Regarding patient examination and lab investigation, the peripheral pulse was lacking in all patients' records, feet examination was recorded for 159 (71.3%) patients, eye examination was missing for 11.2% of patients, and the urine sugar and urine proteins were done to less than half of the patients (44.8% and 43.9%, respectively). Regarding manage-ment and medication, health education and compliance were almost complete. Good diabetes control was achieved among 22.9% of patients only. Non-congruency of patients' data occurred in 11.7% of records.
Recommendations: General practitioner at primary health care units should be educated appropriately about adequate management of diabetes mellitus, early detection and prompt treatment of complications as well as patient's counseling. There is a need to formulate the local standards of care and clinical practice guidelines for the management of diabetes that are easily affordable and available to the health care providers and more appropriate and suitable for our part of the world.