Suboptimal clinical record keeping presents a problem in managing ill children throughout the continuum of care for both acute and chronic conditions. For children this is exacerbated by the fact that they are not able to well articulate any previous health system encounters and the outcomes thereof. To address this problem, the CHAMPS team at Bangabandhu Sheikh Mujib Medical College Hospital (BSMMCH), Faridpur, Bangladesh in collaboration with hospital management and staff, introduced a structured clinical form in the Special Care Newborn Unit  (SCANU). The aim was to enhance completeness and quality of clinical data for better patient care of newborns. Gaps in documentation of clinical information (comprehensive and well-documented clinical and laboratory information) were identified as a contributor to preventable causes of deaths in newborns and children under 5 years of age. This intervention was developed as a data-to-action initiative, working closely with clinicians involved in newborn care with a four-phase approach – development, piloting, revision, and finalization. The finalized form was introduced for all admitted neonates at the SCANU of BSMMCH starting from September 4, 2023. Preliminary assessments indicate improved completeness of clinical data in key areas such as symptoms during hospital admission, birth history, and clinical examination findings. However, capturing information from laboratory and other investigations remains a challenge.

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Enhancing clinical data completeness and integrity for improved patient care