DEDER GENERAL HOSPITA weekly

senior chart round report

Reviewers:
1. Dr. Anwar Sham (MD, Senior Gynecologist)
2. Abdi Tofik (BSc, MPH, QU)
3. Hamza Abdulmalik (BSc, QU)

Date: Jan 15, 2016EFY

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 TABLE OF CONTENTS

TABLE OF CONTENTS
TABLE OF CONTENTS...............................................................................................................ii
LIST OF FIGURES....................................................................................................................... ii
1. INTRODUTION.................................................................................................................... 3
2. OBJECTIVES........................................................................................................................ 4
2.1. General objective
............................................................................................................................ 4
2.2. Specific objectives
...........................................................................................................................4
3. Method and materials............................................................................................................. 5
3.1. Study Period....................................................................................................................5
3.2. Study design....................................................................................................................5
3.3. Source population............................................................................................................5
3.4. Study population............................................................................................................. 5
3.5. Sample size determination & sampling technique...............................................................6
3.5.1. Sample size determination...............................................................................................6
3.5.2. Sampling technique.........................................................................................................6
3.5.3. Data processing & analysis.................................................................................................7
4. RESULT.................................................................................................................................8
4.1. Findings of weekly Seniors charts round of three months...................................................8
4.2. Rational use of drugs (i.e. avoid extravagancy, over prescription, under prescription,
multiple prescription, & incorrect prescribing)............................................................................10
6. Reference..............................................................................................................................12

ii
 LIST OF FIGURES
Figure 1: Findings of weekly Seniors charts round, DGH 2016EFY(N=9)....................................10
Figure 2: Rational use of drugs among reviewed chart of DGH, 2016EFY(n=9).................11

iii
 1. INTRODUTION
Senior chart review is a review of patient charts performed by

selecting sampled charts that had discharged during a given

week. The focus is to see the complete the completeness of the

charts and presence of senior notes in the charts as well as to

work on the gap identified in order to provide quality health care

for the admitted patients.

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 2. OBJECTIVES
General objective
2.1.
 To address clinical evaluation and decision process, use of an appropriate
and justified work up, rational use of drugs, and nursing care
Specific objectives
2.2.
 To identify the presence of junior physician decision making process
 To identify the appropriate Nursing care plan
 To identify irrational drug use
 To work on the identified gaps

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 3. Method and materials
3.1. Study Period
This senior chart round was conducted in Gyn/OBS Department of Deder General
Hospital using the patient’s charts discharged from 9/05- 15/05/2016 EFY

3.2. Study design

 Hospital based retrospective study

3.3. Source population

 All admitted cases at the Gyn/OBS ward during the audit period

3.4. Study population

 All admitted cases at Deder General Hospital who fulfill inclusion criteria
during the study period.

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 3.5. Sample size determination & sampling technique

3.5.1. Sample size determination

 No need of calculating sample size, all charts that are admitted in the study
period were selected from the registration that fulfill the inclusion criteria

3.5.2. Sampling technique

 Convenience sampling techniques was used.

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 3.5.3. Data processing & analysis

 All collected data from checklist was checked manually before entry to
software. Then, the data was entered into an Excel sheet
 Descriptive analysis was carried out for each of the variables to check
frequency, distribution and missing value.

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4. RESULT

4.1.Findings of weekly Seniors charts round of three months

According to the findings of this chart review, of the total of 9 reviewed patient
charts complete history taking that support the working diagnosis & rule out the
DDx, appropriate Ix, DX, & appropriate NCP was performed for all 9(100%) of the
discharged patients. However, complete P/E was performed for only 5(55.6%)
while appropriate treatment was done for only 6(67%) (fig 1).

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 Findings of weekly Seniors charts round (HX, P/E, Ix, Rx, & NCP)
100 100 100 100
100
90
80 67
70 55.6
60 44.4
50
33
40
30
20
10 0 0 0 0
0

in
g
P/
E gs ku
p G ne
ak e di
n
or ST do
t et fin w ith P
Hx pl & NC
e m P/
E
E, tw te
et Co P/ en ia
pl d & , r
m te Hx Hx em ro
p
co u c
on re p
ed nd d on ag Ap
d in
rm co se se d
rfo ba ba an
pe o ne Dx te
d
.d te a
s t ria re
ve p l yt
in p ro te
te A p ir a
ria ro
p
op p
pr Ap
Ap

YES(%) NO(%)
Figure 1: Findings of weekly Seniors charts round, DGH 2016EFY(N=9)

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 4.2.Rational use of drugs (i.e. avoid extravagancy, over prescription, under
prescription, multiple prescription, & incorrect prescribing)
As it was revealed by the finding of this chart review, rational use of drugs at

RATIONAL USE OF DRUGS

78%
80%

70%

60%

50%
Series1
40%

30% 22%
20%

10%

0%

OBGYN Ward was reviewed and out of 9 reviewed charts only 7(78%) used
the rational drugs (Figure 2).
Figure 2: Rational use of drugs among reviewed chart of DGH, 2016EFY(n=9)

5. ACTION PLAN FOR IDENTIFIED GAPS

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S/ Gaps Action to be Responsible Time
N taken body frame

1. no appropriate P/E conduct all seniors ASAP

conducted appropriate p/e
2. No appropriate treatment To give all seniors ASAP
appropriate
treatment
3.

4.

5.

6.

6. Reference
1. Gezmu T, Regassa B, Manilal A, et al. Prevalence, diversity and antimicrobial resistance of
bacteria isolated from the UTI patients of Arba Minch province, Southern Ethiopia. Transl Biomed
2016; 7: 3
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2. Wettermark B, Elseviers M, Almarsdóttir AB, et al. Introduction to drug utilization research.
Drug Utilization Research:Methods and Applications, 2016, pp. 1–12, https://www.whocc.
no/filearchive/publications/drug_utilization_research.pdf
3. Kanakambal S, Murugesh N and Shanthi M. Drug prescribing pattern in a tertiary care teaching
hospital in Madurai (Tamilnadu). Indian J Pharmacol 2001; 33(3): 223.
4. World Health Organization. Promoting rational use of medicines. Geneva: WHO Regional
Office for South-east Asia, 2011.
5. Figueras A. The use of drugs is not as rational as we believe. . .but it can’t be! The emotional
roots of prescribing. Europ J Clin Pharmacol 2011; 67: 433–435

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