JMIR Publications

ABSTRACT

Background:

Inpatient face sheets are foundational admission documents that support patient identification, continuity of care, accountability, and reliable hospital reporting. In many low- and middle-income settings, documentation remains paper-based and vulnerable to incompleteness, which may also undermine readiness for digital health implementation. Evidence on face-sheet completeness and its determinants in tertiary hospitals in sub-Saharan Africa remains limited

Objective:

The study aimed to assess the completeness of inpatient face-sheet documentation at Mulago National Referral Hospital, identify factors associated with incomplete face sheet filling, and also identify the possible solutions. The study also examines the implications of these incomplete face-sheets to the readiness for implementing digital health within this hospital

Methods:

We conducted a cross-sectional mixed-methods study at Mulago National Referral Hospital, Uganda. Quantitatively, we retrospectively reviewed 384 inpatient face sheets (128 per department: Medicine, Surgery, Pediatrics) from files of discharged patients previously admitted for ≥7 days. Thirteen core fields were assessed and coded as filled (1), not filled (0), or not applicable (9), and an overall completeness score (%) was computed. Qualitatively, we conducted three Focus Group Discussions (FGDs) with clinicians and 15 Key Informant Interviews (KIIs) with administrators, and records personnel, and analyzed data using inductive thematic analysis with triangulation across data sources

Results:

Completion was high for patient identifiers and administrative fields, including surname and other names (99.7%), sex (99.2%), registration number (98.7%), age (97.9%), admitting ward (95.8%), and district (95.3%). In contrast, clinical and accountability fields completion was low: days of stay (8.9%), final diagnosis (31.5%), clinical summary (29.4%), doctor’s name (25.0%), and doctor’s signature (28.6%). Only 13/384 face sheets (3.4%) achieved 100% completion. The mean overall completeness score was 69.3% (SD 14.2) with a median of 61.5% and a range of 38-100%. Qualitative findings identified behavioral and attitudinal barriers, training and orientation gaps, weak supervision and accountability, high workload and staffing constraints, and patient-related complexities (e.g., unknown patients) as key drivers. Proposed solutions emphasized strengthened supervision and spot checks, structured training and mentorship integrated into routine practice, improved task sharing and records staffing, use of visual job aids, incentives, and staged digitization.

Conclusions:

In a high-volume tertiary hospital in Uganda, inpatient face sheets were largely complete for demographic identifiers but substantially incomplete for clinical and accountability fields that are critical for safe care, reporting, and quality improvement. Addressing workforce, supervision, training, and role-clarity gaps is essential to improve documentation and to establish the data-quality foundation required for successful digital health implementation.