The Impact of Effective Medical Record Keeping in Shaping Clinical Site Perceptions

In the realm of evidence-based medicine, the importance of available data in ensuring better and ethical patient care is increasing. Medical record keeping (MRK), is crucial to research and the fast-growing field of clinical research and development. This study explored the perspectives of various hospital stakeholders – including doctors, staff, and members of the Ethical Committee (EC) – regarding the markers that define a proficient center based on good MRK practices. Using a Likert scale, 318 respondents from different affiliations (public, private, or both) assessed 10 specific markers. Comparing roles and affiliations, the study revealed significant differences in 7 out of the 10 markers; particularly in areas such as institutional support, training, presence of registered Ethics committees, documentation standards, recruitment procedures, and internal quality assurance. When comparing public and private sector affiliates, differences persisted in 9 markers. Notably. The representation from the public sector was limited (19.8%), highlighting the necessity for broader involvement of stakeholders, especially from secondary and tertiary patient care levels, to achieve a comprehensive understanding.