Mind the Gap: A Clinical Audit of Asthma and COPD Documentation Practices at a University Primary Care Clinic in Selangor, Malaysia

Abstract

Introduction: Clinicians are responsible for meticulous documentation and maintaining a systematic record-keeping system. Good documentation practices improve patient care and uphold quality assurance. This audit assessed documentation practices during asthma and COPD clinic consultations. Methods: This retrospective descriptive audit examined electronic medical records (EMRs) for documentation completeness of asthma and COPD patients attending a university primary healthcare clinic in Selangor, Malaysia, from January 1, 2020, to December 31, 2020. Patients’ EMRs meeting the inclusion/exclusion criteria were evaluated using standardised checklists to collect sociodemographic and clinical data, including selected asthma and COPD indicators across three domains: clinical assessment, disease control assessment, and disease management. Documentation completeness for each indicator was recorded and marked as “Yes” for documented or “No” for undocumented. Data were analysed using IBM SPSS V26.0. Results: 180 asthma and 15 COPD patients’ EMRs were analysed. The asthma cohort had a mean age of 54.46 (SD:18.99), were predominantly female (61.7%), Malay (92.8%) and obese (54.9%). The COPD cohort had a mean age of 73.67 (SD: 7.61), were mostly male (80.0%), Malay (73.3%) and overweight (54.5%). In asthma documentation, four indicators achieved > 50%, while the remaining four indicators achieved <50% completion rates. In COPD documentation, four indicators achieved >50%, while seven indicators achieved <50% completion rates. Conclusions: Documentation completion for asthma and COPD care indicators fell below targets. Regular training, feedback and audits are crucial for enhancing documentation, improving care and minimising medicolegal risks. Study limitations include variability in documentation practices and the generalizability of findings to a single setting.