الملخص الإنجليزي
Objectives: To audit the documentation of medical care provided to hypertensive patients and to evaluate the management of hypertension in a primary healthcare center, Family Medicine Staff Clinic, Sultan Qaboos University (SQU) in Oman.
Methods: An audit of electronic medical records (EMR) was carried out during 2007and 2008 on a representative sample of 150 patients, selected randomly using a simple randomization method. The mean age of the patients was 54.8 +/- 9.9 years. The majority were Omanis; 53.3% were female, 46.7% were male. All patients' records were reviewed for proper recording in a pre designed structured form. Re-auditing was done in 2008. McNemar's test was used to compare data in 2007 with data in 2008.
Results: Age, gender, blood pressure recording, renal function tests, and lipid levels were sufficiently recorded (>75%) in the computer system. Histories of pertinent symptoms and smoking history were poorly recorded (<1%). Fifty-five percent of the hypertensive patients were sufficiently controlled (BP<140/90). There were significant differences between 2007 and 2008 with respect to documentation and recording of pertinent symptoms (p<0.001) and renal function tests (p=0.026).
Conclusion: Conducting an audit of EMR is essential to evaluate clinical performance and to determine what changes should be made to improve quality of care. There was significant improvement in documentation of pertinent symptoms in the second audit.
