Completeness of Paper-Based Clinical Records as a Dimension of Clinical Record Quality in Selected Public Hospitals in Mpumalanga and Eastern Cape Provinces, South Africa.

Background

Clinical documentation is fundamental to quality healthcare delivery, continuity of care, clinical governance, health information management, and medico-legal accountability. However, incomplete clinical documentation remains a persistent challenge in public healthcare settings, and evidence describing documentation completeness at the hospital level in South Africa remains limited. Aim: This study aimed to assess the completeness of paper-based clinical records in selected public hospitals in the Mpumalanga and Eastern Cape provinces of South Africa.

Methods

A quantitative cross-sectional clinical record audit was conducted in four public hospitals located in the Ehlanzeni District of Mpumalanga Province and the OR Tambo District of the Eastern Cape Province. A total of 255 randomly selected patient records from major clinical departments were audited using a structured data extraction instrument. Documentation completeness was assessed across seven domains: patient identification, professional identification, record structure, timing documentation, consent documentation, form completion, and clinical care documentation. Descriptive statistics summarised documentation completeness. One-way analysis of variance (ANOVA) compared mean completeness scores between hospitals, while Fisher's exact test examined associations between hospitals and overall completeness categories.

Results

Overall clinical documentation completeness was moderate (mean = 54.5%, SD = 8.1). Timing documentation (96.6%) and clinical care documentation (90.3%) demonstrated the highest completeness, whereas professional identification (37.5%), consent documentation (0.4%), and completion of mandatory clinical forms (1.0%) showed substantial deficiencies. Overall completeness differed significantly between hospitals (F = 14.6, p < 0.001), with RFH and Themba Hospital achieving significantly higher mean completeness scores than NMAH and SEH. Most records (69.8%) were classified as having poor completeness, 29.8% demonstrated moderate completeness, and only one record (0.4%) achieved good completeness.

Conclusions

The findings demonstrate that documentation completeness represents only one dimension of clinical record quality and highlight opportunities to strengthen documentation practices within the participating rural public hospitals. Future research should evaluate interventions that improve documentation completeness alongside other dimensions of clinical record quality.