Effect of Improper Documentation of Health Records

ABSTRACT

Documentation in medical record is the basis for communication between health professionals which inform the care provided, the treatment rendered, care planned and the outcome of that care as a continuous and existing record. Health information documentation is a document about healthcare services that is provided to an individual patient. If documentation doesn’t give a clear presentation of a patient’s history, it is termed improper documentation. Thus, this study aims to determine the level of patient documentation practice and ascertained the technical knowledge possessed by health record staff practicing documentation

 A descriptive research design was used and a convenient sampling technique was employed to administer questionnaire to health records staff in University College Hospital. A total of 150 participants were used and 114 questionnaires were retrieved. The data collected were analyzed using frequency table and simple percentages, with the aid of statistical package for social sciences (SPSS) version 16..

It was discovered that majority of the respondents 87(76.3%) have adequate knowledge about documentation and almost all 113(99.1%) of the respondents said training is required for proper documentation. Findings revealed that factors that contribute to improper documentation include   lack of time to document patient care, insufficient staff, illegibility of handwriting, lack of interest, lack of conducive working environment, inadequate knowledge concerning the importance of documentation and shortage of materials for documentation.  Results of improper documentation include patient death, litigation cases and complications in patient health.

Finally, this study has showed clearly the impact of improper documentation among health records staff, which facilitates diagnosis and treatment, communicates pertinent information to the other caregivers to ensure patient safety, reduce medical error and serves as an important medico-legal function in risk management. In conclusion, based on this findings management should conduct periodic training and re-training of healthcare professionals to improve documentation for effective documentation process and government should provide the health records staff with the required needed materials to document accurately.

CHAPTER ONE

INTRODUCTION

1.1 Background to the studyAccording to Paul and Thomas (2013) Documentation is vital to safe, ethical, and effectivenursing practice in clinical areas. Nursing practice requires documentation to ensure continuityof care, planning, and accountability, as well as in the promotion and uptake of evidence-basedpractice, documentation provides a method of evaluating the quality system performance of thesupplier to sense the provider of quality material and product  is selected.  In acuminate careoperation or treatment, it is critical to document each patient condition and history of care, toensure the patient receives the adequate health care, the information must be passed through allthe health professionals of the care giver, adequate documentation is always important in a healthcare setting. Albaelak, (2010).Documentation is a necessary component of safe, ethical and effective medical practice. Healthprofessional   are   required   to   document   and   keep   records   of   their   professional   practice   inaccordance with standard  of  practice, and organizational  policies  and  procedures.  As healthprofessional, the health and care of patient is of greatest concerns, and it is clear that inadequateclinical documentation impact on both patient care and outcomes. For instance, a family doctortreating a patient without the benefit of a discharge summary from an acute care, physician isworking at a disadvantage in a potentially life-threatening situation. Therefore, quality physiciandocumentation shared in a timely manner can be of help to avoid negative consequences, such asadverse medication events. Martin, (2012).  According to Malcoh (2012), documentation can bedefined as a clear concise and accurate history of the patient’s life and illness written from themedical point of view. He went further to say that before the records can be completed, it mustcontain sufficient data written in sequence of event to justify the diagnosis and warrant thetreatment and the end result.