The Moroccan medical file between practice and politics: a cross-sectional study
INTRODUCTION: The medical file is a key element of quality reflecting good hospital management. Many steps have been taken through its history leading up to computerization. This Process allows the sharing of files with both the health staff and patients, while respecting the professional confidenti...
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| Format: | Article |
| Language: | English |
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The Pan African Medical Journal
2021-02-01
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| Series: | The Pan African Medical Journal |
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| Online Access: |
https://www.panafrican-med-journal.com/content/article/38/153/pdf/153.pdf
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| _version_ | 1819281793865482240 |
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| author | Naouadir Rajae Cheikh Amine Ajaja Mohamed Rida Bouatia Mustapha Naji Saida El Hassani Amine |
| author_facet | Naouadir Rajae Cheikh Amine Ajaja Mohamed Rida Bouatia Mustapha Naji Saida El Hassani Amine |
| author_sort | Naouadir Rajae |
| collection | DOAJ |
| description | INTRODUCTION: The medical file is a key element of quality reflecting good hospital management. Many steps have been taken through its history leading up to computerization. This Process allows the sharing of files with both the health staff and patients, while respecting the professional confidentiality between parties. However, in Morocco, as is the case in other countries that are unable to computerize all their hospitals, it is necessary to study first the medical file in paper before proceeding with its computerization. The purpose of our study is to describe the state of the hard copy medical record in our Host University and international hospital, Cheikh Zaid in Morocco. METHODS: that is a cross-sectional study that lasted for three months in Cheikh Zaid hospital. The collection of data from this institution was based on the evaluation of 100 medical records of inpatients, seeing as they respond to our study criteria and requirements better than outpatients. Said evaluation was inspired by a clinical audit grid recommended by the High Authority for Health (HAS). Extraction of the results is done using the SPSS 13.0, Microsoft Excel, and Microsoft Visio software. In addition, we used the observation method to correct the errors found. RESULTS: the results showed that 75% of the files are in good condition and well organized. However, administrative documents were missing in 70% of the cases (national identity card, health insurance card and copy of the patient´s consent form). Moreover, in 83% of cases, the identity of the person to be notified in case of complications and the consent form were missing. It is also the case for the discharge report. The latter is incomplete in 97% of the cases. Also, the file transfer data from one service to another were missing in 82% of the medical files. CONCLUSION: according to the results, improving the medical file is necessary both administratively and medically. Thus, all parties, including doctors and nurses must be aware of their tasks and roles in this process. Despite the advances in the computerization of the medical file in several hospitals in Morocco, the maintenance of the hard copy version remains unavoidable and still necessary, to protect the rights of both the patient and his medical staff. |
| first_indexed | 2024-12-24T01:05:21Z |
| format | Article |
| id | doaj.art-f4dc8e1e8d4f455cb385c09581ae66ed |
| institution | Directory Open Access Journal |
| issn | 1937-8688 1937-8688 |
| language | English |
| last_indexed | 2024-12-24T01:05:21Z |
| publishDate | 2021-02-01 |
| publisher | The Pan African Medical Journal |
| record_format | Article |
| series | The Pan African Medical Journal |
| spelling | doaj.art-f4dc8e1e8d4f455cb385c09581ae66ed2022-12-21T17:23:14ZengThe Pan African Medical JournalThe Pan African Medical Journal1937-86881937-86882021-02-013815310.11604/pamj.2021.38.153.1633016330The Moroccan medical file between practice and politics: a cross-sectional studyNaouadir Rajae0Cheikh Amine1Ajaja Mohamed Rida2Bouatia Mustapha3Naji Saida4El Hassani Amine5 Mohammed V University, Faculty of Juridical, Economic and Social Sciences, Mohammed Ben Abdallah Avenue Ragragui Al Irfane, Zip code 6430, Rabat Institutes, Rabat, Morocco Abulcasis University, Faculty of Pharmacy, Cheikh Zaid Hospital, Department of Pharmacy, Al Irfane City, Hay Ryad, Allal Al Fassi Avenue, Zip code 6533, Rabat, Morocco Abulcasis University, Faculty of Medicine, Cheikh Zaid Hospital, Department of Cardiac Surgery, Al Irfane City, Hay Ryad, Allal Al Fassi Avenue, Zip code 6533, Rabat, Morocco Mohammed V University, Faculty of Medicine and Pharmacy, Children's Hospital, Ibn Sina University Hospital Mohammed V University, Faculty of Juridical, Economic and Social Sciences, Mohammed Ben Abdallah Avenue Ragragui Al Irfane, Zip code 6430, Rabat Institutes, Rabat, Morocco Mohammed V University, Faculty of Medicine and Pharmacy, Cheikh Zaid Hospital, Department of Pediatrics, Al Irfane City, Hay Ryad, Allal Al Fassi Avenue, Zip code 6533, Rabat, Morocco INTRODUCTION: The medical file is a key element of quality reflecting good hospital management. Many steps have been taken through its history leading up to computerization. This Process allows the sharing of files with both the health staff and patients, while respecting the professional confidentiality between parties. However, in Morocco, as is the case in other countries that are unable to computerize all their hospitals, it is necessary to study first the medical file in paper before proceeding with its computerization. The purpose of our study is to describe the state of the hard copy medical record in our Host University and international hospital, Cheikh Zaid in Morocco. METHODS: that is a cross-sectional study that lasted for three months in Cheikh Zaid hospital. The collection of data from this institution was based on the evaluation of 100 medical records of inpatients, seeing as they respond to our study criteria and requirements better than outpatients. Said evaluation was inspired by a clinical audit grid recommended by the High Authority for Health (HAS). Extraction of the results is done using the SPSS 13.0, Microsoft Excel, and Microsoft Visio software. In addition, we used the observation method to correct the errors found. RESULTS: the results showed that 75% of the files are in good condition and well organized. However, administrative documents were missing in 70% of the cases (national identity card, health insurance card and copy of the patient´s consent form). Moreover, in 83% of cases, the identity of the person to be notified in case of complications and the consent form were missing. It is also the case for the discharge report. The latter is incomplete in 97% of the cases. Also, the file transfer data from one service to another were missing in 82% of the medical files. CONCLUSION: according to the results, improving the medical file is necessary both administratively and medically. Thus, all parties, including doctors and nurses must be aware of their tasks and roles in this process. Despite the advances in the computerization of the medical file in several hospitals in Morocco, the maintenance of the hard copy version remains unavoidable and still necessary, to protect the rights of both the patient and his medical staff. https://www.panafrican-med-journal.com/content/article/38/153/pdf/153.pdf patient´s medical recordcomputerizationtraceability |
| spellingShingle | Naouadir Rajae Cheikh Amine Ajaja Mohamed Rida Bouatia Mustapha Naji Saida El Hassani Amine The Moroccan medical file between practice and politics: a cross-sectional study The Pan African Medical Journal patient´s medical record computerization traceability |
| title | The Moroccan medical file between practice and politics: a cross-sectional study |
| title_full | The Moroccan medical file between practice and politics: a cross-sectional study |
| title_fullStr | The Moroccan medical file between practice and politics: a cross-sectional study |
| title_full_unstemmed | The Moroccan medical file between practice and politics: a cross-sectional study |
| title_short | The Moroccan medical file between practice and politics: a cross-sectional study |
| title_sort | moroccan medical file between practice and politics a cross sectional study |
| topic | patient´s medical record computerization traceability |
| url |
https://www.panafrican-med-journal.com/content/article/38/153/pdf/153.pdf
|
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