Data quality assessment in healthcare: a 365-day chart review of inpatients' health records at a Nigerian tertiary hospital
| Autor: | AbdulLateef Adisa Adebisi, Samuel Adebowale Adefemi, Moses Esimy Atakere, Muhammad Wasagi Hassan, Sunday Adesubomi Erinle, Abdullahi Daniyan Jibril, Adedeji Olugbenga Adekanye, John Adeniran James, Oluwaseun Ayoade Abodunrin, Moses Achinbee, Kayode Abiodun Onawola, Oloundare Olanrewaju AbdulGhaney, Olubunmi Edith Yahaya, Ibrahim Taiwo Adeleke, AbdurRahman Alhaji Shehu, Alaba George Okuku, Lateef Mosebolatan Ogundiran |
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| Rok vydání: | 2012 |
| Předmět: |
Quality Control
medicine.medical_specialty MEDLINE Nigeria Health Informatics Documentation Health records Research and Applications Medical Records Tertiary Care Centers Unique identifier Health care Humans Medicine business.industry Medical record Reproducibility of Results Retrospective cohort study medicine.disease Patient Discharge Data quality Emergency medicine Management Audit Medical emergency business |
| Zdroj: | Journal of the American Medical Informatics Association. 19:1039-1042 |
| ISSN: | 1527-974X 1067-5027 |
| DOI: | 10.1136/amiajnl-2012-000823 |
| Popis: | Background 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. |
| Databáze: | OpenAIRE |
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