EFFECTS OF IMPROPER DOCUMENTATIONS OF HEALTH RECORDS

Abstract

This study was on effects of improper documentations of health records. Three objectives were raised which included:  To ascertain the importance of records management practice to health staff, to identify the state of records management practice at health facilities, to assess how record management affects the quality of health service delivery at the various health facilities and tassess the availability of capacity for electronic records management in terms of human resources in the various health. A total of 77 responses were received and validated from the enrolled participants where all respondents were drawn from selected hospitals in Lagos. Hypothesis was tested using Chi-Square statistical tool (SPSS).

 Chapter one

Introduction

1.1Background of the study

According to Paul and Thomas (2013) Documentation is vital to safe, ethical, and effective nursing practice in clinical areas. Nursing practice requires documentation to ensure continuity of care, planning, and accountability, as well as in the promotion and uptake of evidence-based practice, documentation provides a method of evaluating the quality system performance of the supplier to sense the provider of quality material and product is selected.  In acuminate care operation or treatment, it is critical to document each patient condition and history of care, to ensure the patient receives the adequate health care, the information must be passed through all the 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. Health professional   are   required   to   document   and   keep   records   of   their   professional   practice   in accordance with standard  of  practice, and organizational  policies  and  procedures.  As health professional, the health and care of patient is of greatest concerns, and it is clear that inadequate clinical documentation impact on both patient care and outcomes. For instance, a family doctor treating a patient without the benefit of a discharge summary from an acute care, physician is working at a disadvantage in a potentially life-threatening situation. Therefore, quality physician documentation shared in a timely manner can be of help to avoid negative consequences, such as adverse medication events. Martin, (2012).  According to Malcoh (2012), documentation can be defined as a clear concise and accurate history of the patient’s life and illness written from the medical point of view. He went further to say that before the records can be completed, it must contain sufficient data written in sequence of event to justify the diagnosis and warrant the treatment and the end result.

Patients’ records are needed every day to record information about the patients’ personal particulars, prescriptions and diagnosis for future reference to follow-up patients. The information recorded is ultimately used to substantiate the patients’ health record during present and future consultations. The paces at which the records are retrieved and served for this purpose determine the patient waiting time for the services. Proper filing of patient’s medical records facilitates effortless retrieval and ensures reduction patient’s waiting time at the hospital and ensures continuity of care. It is therefore, very important, that medical records are always kept in the interest of both the clinician and the patient. The medical folder must always be in the safekeeping of the health facility whiles the patient enjoys the right of information. Studies in other developing countries have observed their record keeping systems to be inadequate with about half (52.2%) of the records retrievable within one hour (Aziz & Rao, 2002), and a number the records were badly designed and there is use of multiple patient health records by patients (Kerry, 2006).

Statement of the problem

An effective management of hospital records is a critical factor in providing capacity for hospitals’ efficiency, accountability, transparency, information security and indeed good governance. Currently, findings indicate that in Ghana, there are inadequate records management practice in most institutions including the health sector simply because many existing record keeping systems of some hospitals were found not designed to collect information on some diseases (Danquah, appah, Djan, Ofori, Essegbey & Opoku, 1997). As a result, health workers more often than not end up not rendering certain services because the health history of the patient is not contained in medical files. This is owing to the fact that, if the health personnel continue treating patients exclusive of sufficient information about the patients’ health conditions the individuals could end up rendering poor health care that may be unsafe to patients’ health.

Objective of the study

1. To ascertain the importance of records management practice to health staff.
2.  To identify the state of records management practice at health facilities.
3. To assess how record management affects the quality of health service delivery at the various health facilities.
4.  To assess the availability of capacity for electronic records management in terms of human resources in the various health.

Research Hypotheses

The following research hypotheses were formulated;

H0: there is no importance of records management practice to health staff.

H1: there is importance of records management practice to health staff.

H0: record management do not affects the quality of health service delivery at the various health facilities

H2: record management affects the quality of health service delivery at the various health facilities

Significance of the study

This research will assist the Ministry of Health and its facilities in revealing, identifying and recommending the required modern record management practice system which will enable the health facilities to render quality health care service. The findings and recommendations of this study may be used by ministry of health to advance the health services to implementing an effective records management practice.

Scope of the study

The scope of the study covers effects of improper documentation of health records. The study will be limited selected hospitals in Lagos state

Limitation of the study

Limitations/constraints are inevitable in carrying out a research work of this nature. However, in the course of this research, the following constraints were encountered thus:

1. Non-availability of enough resources (finance): A work of this nature is very tasking financially, money had to be spent at various stages of the research such resources which may aid proper carrying out of the study were not adequately available.
2. Time factor: The time used in carrying out the research work is relatively not enough to bring the best information out of it. However, I hope that the little that is contained in this study will go a long way in solving many greater problems.

Definition of terms

Improper documentation: 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

Health record:​A health record is a confidential compilation of pertinent facts of an individual’s health history, including all past and present medical conditions

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