Organizational mechanisms and modern trends in ensuring the quality of medical documentation in Georgian clinics
DOI:
https://doi.org/10.52340/healthecosoc.2026.10.01.14Keywords:
clinical management, patient safety, Medical records, quality assurance, Electronic Health RecordsAbstract
Introduction: Medical records are critical to patient care and clinical management, making continuous quality improvement essential. This study aims to evaluate the role of medical records in hospital performance, identify factors affecting documentation quality, and assess the transition from paper-based histories to Electronic Health Records (EHR). Methodology: A qualitative approach was employed, using semi-structured in-depth interviews with healthcare quality managers. Additionally, desk research was conducted to analyze international best practices, industry standards, and the regulatory framework of Georgia's healthcare sector. Results: The quality of medical records directly correlates with hospital management efficiency and patient safety. Beyond technical and human factors, quality is heavily influenced by internal hospital policies and incentive/penalty systems. EHR implementation significantly reduces data loss and improves accessibility, though it introduces technological adaptation barriers for staff. Conclusion: Ensuring documentation quality requires a systemic approach. This involves integrating digital tools, optimizing internal organizational hierarchies, providing continuous staff training, and strengthening the functional capacity of quality management departments.
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