Improving Documentation of Cardio Vascular Disease Risk in Medical Records of Diabetic Patients attending Non Communicable Disease Clinics at West Bay Health Center in Qatar
Background Patients with type 2 diabetes have an increased prevalence of lipid abnormalities, contributing to their high risk of CVD. Multiple clinical trials have demonstrated significant effects of pharmacological (primarily statin) therapy on CVD outcomes in individual subjects with CHD and for primary CVD prevention. Our aim is to improve documentation of cardiovascular disease risk in medical records of diabetic patients attending non communicable disease clinics at west bay health center from 13% to 70% using world health organization cardiovascular disease risk Prediction Charts from September 2014 to January 2015. Methods Baseline audit to determine the percentage of cardiovascular disease risk documentation, Brain storming session was done to identify the causes of such problem including fish bone analysis, Survey questionnaire was designated to assess the main causes of the problem and distributed to all nurses working in non communicable disease clinics, The results demonstrated in paretto chart, We discover the main causes of the problem lies on two main causes (nurses were not oriented to new non communicable disease format and some of them were not trained to calculate risk).Intervention in form of: Education session for nurses working in these clinics were done particularly on: Orientation about new format and cardiovascular disease riskdocumentation, Orientation sessions for clinic running physicians, Putting reminder posters in clinics and staff nurse stations. Several audits done retrospectively for two weeks (3 days each week) to show average percentage of documentation in pre intervention stage from 15th September to 13th November 2014, Several audits done for three weeks (3 days each week) and then weekly for 5 weeks to show average percentage in post intervention stage ending at 15th January 2015, All data was demonstrated using run chart. Results The intervention began in November 2014 to January 2015 reveals that: Percentage of complete cardiovascular risk documentation for diabetic patients average was 7% in pre intervention stage and increased to average of 59% after the intervention Conclusions Intervention in the form of nurse education and physician orientation improved Documentation of cardiovascular disease risk by 52% Raising the average of documentation from 7% to 59% Sustainability is very important for success in such improvement processes.