Quality of Documentation in Family Medicine Outpatient Records at Secondary Facilities in Anambra State

Background: High-quality clinical documentation is essential for patient safety, continuity of care, medico-legal protection, and health system data generation. This study assesses the quality of outpatient medical records documentation at family medicine clinics in three general hospitals in Anambra State, South East geopolitical zone. Methods: A retrospective document audit reviewed 360 randomly selected outpatient records from three secondary facilities. Each record was scored against a validated clinical documentation quality checklist covering completeness, legibility, diagnostic coding, and follow-up planning. Descriptive statistics were computed. Results: Documentation quality was suboptimal across all reviewed facilities. Chief complaint and vital signs were frequently recorded; however, clinical reasoning, differential diagnoses, and management plans were often absent or incomplete. Diagnostic coding was rarely applied. Legibility issues were prevalent in handwritten records. Conclusion: Poor documentation quality at family medicine outpatient settings in Anambra State represents a patient safety risk and impedes meaningful health data utilisation. Capacity building in medical record keeping and transition to electronic medical records should be prioritised within the state health system improvement agenda. Keywords: clinical documentation, medical records, outpatient, Anambra State, quality improvement