Published: 2020-03-25

Completeness of information in electronic compared with paper-based patients’ records in a maternity setting in Dakar, Senegal

Mame D. Ndiaye, Mamour Gueye, Simon B. Ndour, Ndama Niang, Ndeye G. Fall, Khalifa Fall, Abdoulaye Diakhate, Mouhamadou Wade, Aliou Diouf, Moussa Diallo, Magatte Mbaye


Background: Evaluate the consistency of information in paper-based records when registered in parallel with an electronic medical record.

Methods: The study was performed at PMSHC in Dakar Senegal. From the end of year 2016, patients’ files were recorded on both paper-based and electronically. Additionally, previous records were electronically registered. To investigate the completeness of records before and after the electronic recording system has been implemented, information about some maternal and fetal/neonatal characteristics were assessed. When the variable was recorded, the system returned 1, unrecorded variables were coded as 0. We then calculated, for each variable, the unrecorded rate before 2017 and after that date. The study period extended from 2011 to June 2019, a nearly ten-year period. Data were extracted from E-perinatal to MS excel 2019 then SPSS 25 software. Frequencies of unrecorded variables were compared with chi-squared test at a level of significance of 5%.

Results: A total of 48,270 unique patients’ records were identified during the eight-year period.  Among the study population, data for patients’ age, address and parity were available most of the time before and after 2017 (0.5% missing data versus 0.3% for age and 2.6% versus 1.3% for home address and from 0.3% to 0.0% for parity). However, phone number, maternal weight, maternal height, last menstrual period and blood group were found to be missing up to 96% before 2017. From 2017, these rates experienced a sudden decrease at a significant level: from 82.4% to 27.8% for phone number, from 96% to 56.3% for maternal weight and from 60.1% to 21.3% for blood group. Regarding newborns’ data, it was found that fetal height, head circumference and chest circumference were missing up to just under 25% before 2017. After that date, their completeness improved and flattened under 5%.

Conclusions: Structured and computerized files reduce missing data. There is an urgent need the Ministry of health provides hospitals and health care providers with guidelines that describes the standardized information that should be gathered and shared in health and care records.


Completeness, Dakar, Electronic medical record, Paper record, Senegal

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Guèye M, Ndiaye Guèye MD, Mbaye M, Abdoulaye M, Diouf A, Wade M, et al. Crossing the line to electronic medical records in Subsaharian Africa: an obstetric and neonatal information system with perinatal indicators dashboard. J Health Sci Res. 2017;2(1):14-20.

Aschengrau A, Seage III GR. Essentials of epidemiology in public health. In: Burlington, MA: Jones and Bartlett Learning. 3rd ed. Michael Brown Publisher; 2020:541.

Al-Awqati Q. How to write a case report: lessons from 1600 B.C. Kidney Inter. 2006;69(12):2113-4.

Dalianis H. Clinical text mining: Secondary Use of Electronic Patient Records. Springer, Cham; 2018:192.

Miller AC. Jundi-Shapur, bimaristans, and the rise of academic medical centres. J Royal Soci Med. 2006;99(12):615-7.

Weed LL. Medical records that guide and teach. New Eng J Med. 1968;278(12):652-7.

Engel L, Henderson C, Fergenbaum J, Colantonio A. Medical record review conduction model for improving interrater reliability of abstracting medical-related information. Eval Health Prof. 2009;32(3):281-98.

Hayward RA, Hofer TP. Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer. JAMA. 2001;286(4):415-20.

Reisch LM, Fosse JS, Beverly K, Yu O, Barlow WE, Harris EL, Rolnick S, Barton MB, Geiger AM, Herrinton LJ, Greene SM. Training, quality assurance, and assessment of medical record abstraction in a multisite study. Am J Epidemiol. 2003;157(6):546-51.

Stein HD, Nadkarni P, Erdos J, Miller PL. Exploring the degree of concordance of coded and textual data in answering clinical queries from a clinical data repository. J Am Med Inform Assoc. 2000;7(1):42-54.

Mikkelsen G, Aasly J. Concordance of information in parallel electronic and paper-based patient records. Int J Med Inform. 2001;63(3):123-31.

Stausberg J, Koch D, Ingenerf J, Betzler M. Comparing paper-based with electronic patient records: lessons learned during a study on diagnosis and procedure codes. J Am Med Inform Assoc. 2003;10(5):470-7.

Lai FW, Kant JA, Dombagolla MH, Hendarto A, Ugoni A, Taylor DM. Variables associated with completeness of medical record documentation in the emergency department. Emerg Med Australas. 2019;31(4):632-8.