Evaluation of Medical Records Quality and the Potential for Digital Health Technologies Integration in the Obstetrics and Gynecology Department at Cairo University Hospital | ||||
| Egyptian Journal of Nutrition and Health | ||||
| Volume 20, Issue 2, July 2025, Page 89-101 PDF (567.07 K) | ||||
| Document Type: Original Article | ||||
| DOI: 10.21608/ejnh.2025.447961 | ||||
 View on SCiNiTO | ||||
| Authors | ||||
| Ola A. Mostafa* 1; Yara Mostafa Mohamed Yassin1; Nadine Sherif2; Doaa A Saleh1 | ||||
| 1Public Health and Community Medicine Department, Cairo University, Egypt. | ||||
| 2Obstetrics and Gynecology Department, Cairo University, Egypt. | ||||
| Abstract | ||||
| High-quality clinical documentation is essential for effective patient management, especially in Obstetrics and Gynecology (OB/GYN), where timely and accurate information impacts maternal and neonatal outcomes. Despite the benefits of Electronic Health Records (EHRs), many healthcare institutions, including those in Egypt, face challenges in maintaining comprehensive and standardized documentation, which may hinder digital transformation efforts. The objective of this study was to evaluate the quality, completeness, and adherence to documentation standards of inpatient clinical records in the OB/GYN department at Cairo University Hospital, to identify gaps that could affect the integration of Digital Health Technologies (DHTs). A descriptive cross-sectional study was conducted on a convenient sample of 100 medical records from OB/GYN inpatient units at Cairo University Hospital between December 2024 and January 2025. A structured observation checklist, adapted from the General Authority for Healthcare Accreditation & Regulation (GAHAR) and Ministry of Health guidelines, was used to assess documentation quality, completeness, timeliness, and regulatory compliance. The results revealed variable compliance with documentation standards. While patient identification was consistently recorded, critical data such as patient address (57%) and date of birth (2%) were often missing. Only 2% of records contained sufficient information to promote continuity of care, and discharge summaries lacked follow-up instructions entirely. Emergency care documentation was present in 86% of cases but often incomplete. Referral documentation was inconsistent, with key transfer details frequently omitted. The study concluded that significant gaps exist in the quality of clinical documentation in the OB/GYN inpatient records at Cairo University Hospital. Addressing these deficiencies through standardized EHR adoption is crucial to support digital transformation and improve patient care and safety. | ||||
| Keywords | ||||
| electronic Health records; documentation quality; digital health technologies | ||||
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