J Am Med Inform Assoc - Data quality assessment in healthcare: a 365-day chart review of inpatients' health records at a Nigerian tertiary hospital.

Tópicos

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Resumo

CKGROUND: Health records are essential for good health care. Their quality depends on accurate and prompt documentation of the care provided and regular analysis of content. This study assessed the quantitative properties of inpatient health records at the Federal Medical Centre, Bida, Nigeria.METHOD: A retrospective study was carried out to assess the documentation of 780 paper-based health records of inpatients discharged in 2009.RESULTS: 732 patient records were reviewed from the departments of obstetrics (45.90%), pediatrics (24.32%), and other specialties (29.78%). Documentation performance was very good (98.49%) for promptness recording care within the first 24 h of admission, fair (58.80%) for proper entry of patient unit number (unique identifier), and very poor (12.84%) for utilization of discharge summary forms. Overall, surgery records were nearly always (100%) prompt regarding care documentation, obstetrics records were consistent (80.65%) in entering patients' names in notes, and the principal diagnosis was properly documented in all (100%) completed discharge summary forms in medicine. 454 (62.02%) folders were chronologically arranged, 456 (62.29%) were properly held together with file tags, and most (80.60%) discharged folders reviewed, analyzed and appropriate code numbers were assigned.CONCLUSIONS: Inadequacies were found in clinical documentation, especially gross underutilization of discharge summary forms. However, some forms were properly documented, suggesting that hospital healthcare providers possess the necessary skills for quality clinical documentation but lack the will. There is a need to institute a clinical documentation improvement program and promote quality clinical documentation among staff.

Resumo Limpo

ckground health record essenti good health care qualiti depend accur prompt document care provid regular analysi content studi assess quantit properti inpati health record feder medic centr bida nigeriamethod retrospect studi carri assess document paperbas health record inpati discharg result patient record review depart obstetr pediatr specialti document perform good prompt record care within first h admiss fair proper entri patient unit number uniqu identifi poor util discharg summari form overal surgeri record near alway prompt regard care document obstetr record consist enter patient name note princip diagnosi proper document complet discharg summari form medicin folder chronolog arrang proper held togeth file tag discharg folder review analyz appropri code number assignedconclus inadequaci found clinic document especi gross underutil discharg summari form howev form proper document suggest hospit healthcar provid possess necessari skill qualiti clinic document lack will need institut clinic document improv program promot qualiti clinic document among staff

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