{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,7]],"date-time":"2026-08-07T17:26:28Z","timestamp":1786123588808,"version":"build-2736575974"},"reference-count":24,"publisher":"MDPI AG","issue":"4","license":[{"start":{"date-parts":[[2026,8,7]],"date-time":"2026-08-07T00:00:00Z","timestamp":1786060800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100001322","name":"South Africa Medical Research Council","doi-asserted-by":"publisher","award":["57035"],"award-info":[{"award-number":["57035"]}],"id":[{"id":"10.13039\/501100001322","id-type":"DOI","asserted-by":"publisher"}]},{"award":["57035"],"award-info":[{"award-number":["57035"]}],"id":[{"id":"https:\/\/ror.org\/05q60vz69","id-type":"ROR","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Med. Sci.","Medical Sciences"],"abstract":"<jats:p>Background: Clinical documentation is fundamental to quality healthcare delivery, continuity of care, clinical governance, health information management, and medico-legal accountability. However, incomplete clinical documentation remains a persistent challenge in public healthcare settings, and evidence describing documentation completeness at the hospital level in South Africa remains limited. Aim: This study aimed to assess the completeness of paper-based clinical records in selected public hospitals in the Mpumalanga and Eastern Cape provinces of South Africa. Methods: A quantitative cross-sectional clinical record audit was conducted in four public hospitals located in the Ehlanzeni District of Mpumalanga Province and the OR Tambo District of the Eastern Cape Province. A total of 255 randomly selected patient records from major clinical departments were audited using a structured data extraction instrument. Documentation completeness was assessed across seven domains: patient identification, professional identification, record structure, timing documentation, consent documentation, form completion, and clinical care documentation. Descriptive statistics summarised documentation completeness. One-way analysis of variance (ANOVA) compared mean completeness scores between hospitals, while Fisher\u2019s exact test examined associations between hospitals and overall completeness categories. Results: Overall clinical documentation completeness was moderate (mean = 54.5%, SD = 8.1). Timing documentation (96.6%) and clinical care documentation (90.3%) demonstrated the highest completeness, whereas professional identification (37.5%), consent documentation (0.4%), and completion of mandatory clinical forms (1.0%) showed substantial deficiencies. Overall completeness differed significantly between hospitals (F = 14.6, p &lt; 0.001), with RFH and Themba Hospital achieving significantly higher mean completeness scores than NMAH and SEH. Most records (69.8%) were classified as having poor completeness, 29.8% demonstrated moderate completeness, and only one record (0.4%) achieved good completeness. Conclusions: The findings demonstrate that documentation completeness represents only one dimension of clinical record quality and highlight opportunities to strengthen documentation practices within the participating rural public hospitals. Future research should evaluate interventions that improve documentation completeness alongside other dimensions of clinical record quality.<\/jats:p>","DOI":"10.3390\/medsci14040464","type":"journal-article","created":{"date-parts":[[2026,8,7]],"date-time":"2026-08-07T16:00:43Z","timestamp":1786118443000},"page":"464","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Completeness of Paper-Based Clinical Records as a Dimension of Clinical Record Quality in Selected Public Hospitals in Mpumalanga and Eastern Cape Provinces, South Africa"],"prefix":"10.3390","volume":"14","author":[{"given":"Siyonela","family":"Mlonyeni","sequence":"first","affiliation":[{"name":"School of Public Health, Walter Sisulu University, Mthatha 5100, South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3857-8225","authenticated-orcid":false,"given":"Ntiyiso Vinny","family":"Khosa","sequence":"additional","affiliation":[{"name":"School of Public Health, Walter Sisulu University, Mthatha 5100, South Africa"},{"name":"Walter Sisulu Institute for Clinical Governance and Healthcare Administration, School of Public Health, Walter Sisulu University, Mthatha 5100, South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Muambangu Jean Paul","family":"Milambo","sequence":"additional","affiliation":[{"name":"School of Public Health, Walter Sisulu University, Mthatha 5100, South Africa"},{"name":"Walter Sisulu Institute for Clinical Governance and Healthcare Administration, School of Public Health, Walter Sisulu University, Mthatha 5100, South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6485-2059","authenticated-orcid":false,"given":"Guillermo Alfredo","family":"Pulido-Estrada","sequence":"additional","affiliation":[{"name":"School of Public Health, Walter Sisulu University, Mthatha 5100, South Africa"},{"name":"Biostatistics and Analytics Training Services Unit, School of Medicine and Health Sciences, Walter Sisulu University, Mthatha 5100, South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6070-2176","authenticated-orcid":false,"given":"Laston","family":"Gonah","sequence":"additional","affiliation":[{"name":"School of Public Health, Walter Sisulu University, Mthatha 5100, South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-0918-7539","authenticated-orcid":false,"given":"Thokoe Vincent","family":"Makola","sequence":"additional","affiliation":[{"name":"School of Public Health, Walter Sisulu University, Mthatha 5100, South Africa"},{"name":"Walter Sisulu Institute for Clinical Governance and Healthcare Administration, School of Public Health, Walter Sisulu University, Mthatha 5100, South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3295-2933","authenticated-orcid":false,"given":"Constance","family":"Rusike","sequence":"additional","affiliation":[{"name":"Department of Human Biology, Faculty of Medicine and Health Sciences, Walter Sisulu University, Mthatha 5117, South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wilson Wezile","family":"Chitha","sequence":"additional","affiliation":[{"name":"School of Public Health, Walter Sisulu University, Mthatha 5100, South Africa"},{"name":"Walter Sisulu Institute for Clinical Governance and Healthcare Administration, School of Public Health, Walter Sisulu University, Mthatha 5100, South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,8,7]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"67","DOI":"10.2147\/RMHP.S179259","article-title":"The role of medical data in efficient patient care delivery: A review","volume":"12","author":"Adane","year":"2019","journal-title":"Risk Manag. Healthc. Policy"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1556","DOI":"10.1016\/j.jiph.2023.07.001","article-title":"Inaccessibility and low maintenance of medical data archive in low-middle income countries: Mystery behind public health statistics and measures","volume":"16","author":"Ghosh","year":"2023","journal-title":"J. Infect. Public Health"},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Solomon, M., Addise, M., Tassew, B., Balcha, B., and Abebe, A. (2021). Data quality assessment and associated factors in the health management information system among health centers of Southern Ethiopia. PLoS ONE, 16.","DOI":"10.1371\/journal.pone.0255949"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1765526","DOI":"10.1080\/16549716.2020.1765526","article-title":"Assessing completeness of patient medical records of surgical and obstetric patients in Northern Tanzania","volume":"13","author":"Lodge","year":"2020","journal-title":"Glob. Health Action"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"275","DOI":"10.1186\/s13690-025-01735-9","article-title":"Negligence in data recording during institutional birth: Exploring health workers\u2019 perspectives on the barriers and enablers of data documentation practices","volume":"83","author":"Taye","year":"2025","journal-title":"Arch. Public Health"},{"key":"ref_6","first-page":"62","article-title":"The District Health Information System (DHIS2): A literature review and meta-synthesis of its strengths and operational challenges based on the experiences of 11 countries","volume":"48","author":"Dehnavieh","year":"2019","journal-title":"Health Inf. Manag. J."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"e001849","DOI":"10.1136\/bmjgh-2019-001849","article-title":"Generating statistics from health facility data: The state of routine health information systems in Eastern and Southern Africa","volume":"4","author":"Jiwani","year":"2019","journal-title":"BMJ Glob. Health"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"14604582221112853","DOI":"10.1177\/14604582221112853","article-title":"Quality of medical records in public health facilities: A case of Southern Ethiopia, resource limited setting","volume":"28","author":"Endriyas","year":"2022","journal-title":"Health Inform. J."},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Siyam, A., Ir, P., York, D., Antwi, J., Amponsah, F., Rambique, O., Funzamo, C., Azeez, A., Mboera, L., and Kumalija, C.J. (2021). The burden of recording and reporting health data in primary health care facilities in five low-and lower-middle income countries. BMC Health Serv. Res., 21.","DOI":"10.1186\/s12913-021-06652-5"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"100218","DOI":"10.1016\/j.ssmhs.2026.100218","article-title":"Data Quality Challenges Compromising the Effective Implementation of the District Health Information System in South Africa","volume":"6","author":"Mwansa","year":"2026","journal-title":"SSM-Health Syst."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"a873","DOI":"10.4102\/sajim.v19i1.873","article-title":"The role of medical records in the provision of public healthcare services in the Limpopo province of South Africa","volume":"19","author":"Marutha","year":"2017","journal-title":"S. Afr. J. Inf. Manag."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"a1230","DOI":"10.4102\/sajim.v23i1.1230","article-title":"Critical success factors to improve data quality of electronic medical records in public healthcare institutions","volume":"23","author":"Makeleni","year":"2021","journal-title":"S. Afr. J. Inf. Manag."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"26","DOI":"10.1186\/1478-4491-12-26","article-title":"South Africa\u2019s protracted struggle for equal distribution and equitable access\u2013still not there","volume":"12","year":"2014","journal-title":"Hum. Resour. Health"},{"key":"ref_14","unstructured":"Raulisa, M. (2022). Determinants of Overcrowding in the Regional Hospital of Vhembe District, Limpopo Province. [Doctoral Dissertation, University of Venda]."},{"key":"ref_15","first-page":"35","article-title":"Access to public health services in South Africa\u2019s rural Eastern Cape Province","volume":"1","author":"Willie","year":"2023","journal-title":"Appl. Sci. Res. Period."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"11786329251356931","DOI":"10.1177\/11786329251356931","article-title":"Barriers and Enablers of Health Services Utilisation in Rural Communities of Nkomazi Sub-District in Mpumalanga Province, South Africa: A Quantitative Community Survey","volume":"18","author":"Metiso","year":"2025","journal-title":"Health Serv. Insights"},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Witter, S., Van Der Merwe, M., Twine, R., Mabetha, D., Hove, J., Tollman, S.M., and D\u2019Ambruoso, L. (2024). Opening decision spaces: A case study on the opportunities and constraints in the public health sector of Mpumalanga Province, South Africa. PLoS ONE, 19.","DOI":"10.1371\/journal.pone.0304775"},{"key":"ref_18","first-page":"1","article-title":"Non-compliant health record-keeping in South Africa: Judicial responses, and progress towards a digital remedy","volume":"2024","author":"Kolawole","year":"2024","journal-title":"Afr. J. Inf. Commun."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1730","DOI":"10.1093\/jamia\/ocad120","article-title":"Electronic health record data quality assessment and tools: A systematic review","volume":"30","author":"Lewis","year":"2023","journal-title":"J. Am. Med. Inform. Assoc."},{"key":"ref_20","first-page":"135","article-title":"Understanding the challenges associated with the use of data from routine health information systems in low-and middle-income countries: A systematic review","volume":"51","author":"Hoxha","year":"2022","journal-title":"Health Inf. Manag. J."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"54","DOI":"10.1007\/s10916-022-01840-0","article-title":"The analyzation of change in documentation due to the introduction of electronic patient records in hospitals\u2014A systematic review","volume":"46","author":"Wurster","year":"2022","journal-title":"J. Med. Syst."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"240","DOI":"10.1093\/jamia\/ocad188","article-title":"The relationship between electronic health records user interface features and data quality of patient clinical information: An integrative review","volume":"31","author":"Madandola","year":"2024","journal-title":"J. Am. Med. Inform. Assoc."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"46","DOI":"10.1007\/s10916-022-01837-9","article-title":"The Impact of Structured and Standardized Documentation on Documentation Quality; A Multicenter, Retrospective Study: Impact of Structured Documentation on Note Quality","volume":"46","author":"Ebbers","year":"2022","journal-title":"J. Med. Syst."},{"key":"ref_24","first-page":"3","article-title":"Natural language processing and String Metric-assisted Assessment of Semantic Heterogeneity method for capturing and standardizing unstructured nursing activities in a hospital setting: A retrospective study| Linguaggio naturale e metodo String Metric-assisted Assessment of Semantic Heterogeneity per standardizzare le attivit\u00e0 infermieristiche documentate in testo libero in ambito ospedaliero: Uno studio retrospettivo","volume":"35","author":"Vanalli","year":"2023","journal-title":"Ann. Ig. Med. Prev. Comunita"}],"container-title":["Medical Sciences"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2076-3271\/14\/4\/464\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,7]],"date-time":"2026-08-07T16:08:29Z","timestamp":1786118909000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2076-3271\/14\/4\/464"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,7]]},"references-count":24,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2026,8]]}},"alternative-id":["medsci14040464"],"URL":"https:\/\/doi.org\/10.3390\/medsci14040464","relation":{},"ISSN":["2076-3271"],"issn-type":[{"value":"2076-3271","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,7]]}}}