COMPLIANCE WITH CLINICAL DOCUMENTATION PRACTICE AMONG MEDICAL DOCTORS IN NATIONAL REFERRAL HOSPITAL IN NAIROBI CITY COUNTY, KENYA
Abstract
Clinical documentation is fundamental to safe and effective patient care, yet global compliance remains below the World Health Organization's recommended 95% standard. In Kenya, compliance stands at 80%, with documented challenges in health information systems contributing to patient mismanagement and medical errors. Limited research has examined clinical documentation compliance among medical doctors in National Referral Hospitals despite their critical role in tertiary healthcare delivery. This study evaluated clinical documentation compliance rates and the influence of sociodemographic characteristics among medical doctors in National Referral Hospitals in Nairobi City County, Kenya. A descriptive analytical cross-sectional study was conducted among 203 medical doctors sampled from three National Referral Hospitals using stratified random sampling. Data were collected using structured questionnaires and the Medical Records Quality Scoring Checklist (MeReQ) to assess compliance across four quality dimensions: completeness, accuracy, legibility, and timeliness. Chi-square tests determined associations between sociodemographic characteristics and compliance at p≤0.05 significance level. Overall compliance was 67%, substantially below both Kenya's 80% and the international 95% standards. Gender (χ²=8.474, p=0.005) and age (χ²=26.732, p=0.001) demonstrated statistically significant associations with compliance. Female doctors showed higher compliance (88.3%) compared to males (72.3%), while mid-career doctors aged 35-47 years exhibited the lowest compliance (49.1%). Work experience, education level, ICT proficiency, and specialization showed no significant associations with compliance. The study concludes that clinical documentation compliance remains suboptimal in National Referral Hospitals. Gender and age significantly influence documentation adherence, necessitating targeted, age-specific and gender-sensitive interventions alongside comprehensive quality improvement frameworks to achieve international standards.
Keywords: Compliance, Clinical Documentation Practice, Medical Doctors, National Referral Hospital, Nairobi City County
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