Quality of hospital admission documentation: A study in an emergency paediatric unit of a tertiary hospital in Nigeria

K. Isezuo, A. Adamu, F. Jiya, T. Yusuf, S. Um, N. Jiya, B. Onankpa, P. Ibitoye, M. Ugege, B. I. Garba
{"title":"Quality of hospital admission documentation: A study in an emergency paediatric unit of a tertiary hospital in Nigeria","authors":"K. Isezuo, A. Adamu, F. Jiya, T. Yusuf, S. Um, N. Jiya, B. Onankpa, P. Ibitoye, M. Ugege, B. I. Garba","doi":"10.5897/AJMHS2018.0021","DOIUrl":null,"url":null,"abstract":"Medical documentation, in addition to being a legal and research tool, is vital in providing quality patient care. In Nigeria, hand written documentation without proforma, is the norm. We assessed the quality of doctors’ documentation of children admitted into Emergency Paediatrics Unit (EPU), Usmanu Danfodiyo University Teaching Hospital (UDUTH). A 3-month cross-sectional study of admission records by different cadre of doctors for children admitted into the EPU between March and May 2016. A checklist was used to assess the quality of documentation. Data was analysed with SPSS version 22. Of the 191 patients’ clerking studied, 63 (33%) indicated the doctors’ cadre. The patients’ name written on the first page in 168 (88%), but only 31 (16.2%) indicated name on subsequent pages. Date and time of consultation were written in 183 (95.8%) and 61 (31.9%) respectively. Writing was legible in (174) 91.1%, with counter-signing of cancellations in 19 (9.9%). Examination findings documented included blood pressure in 18 (9.4%), pulse rate in 179 (93.7%), respiratory rate in 179 (93.7%) and temperature in 184 (96.3%). This study demonstrates the need for improvement in quality of paediatrics emergency documentation. Continuing medical education (CME) on this is essential. \n \n Key words: Quality, admission, documentation, emergency, paediatrics, Sokoto.","PeriodicalId":93249,"journal":{"name":"African journal of medical and health sciences","volume":"525 1","pages":"25-30"},"PeriodicalIF":0.0000,"publicationDate":"2019-07-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"1","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"African journal of medical and health sciences","FirstCategoryId":"1085","ListUrlMain":"https://doi.org/10.5897/AJMHS2018.0021","RegionNum":0,"RegionCategory":null,"ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"","JCRName":"","Score":null,"Total":0}
引用次数: 1

Abstract

Medical documentation, in addition to being a legal and research tool, is vital in providing quality patient care. In Nigeria, hand written documentation without proforma, is the norm. We assessed the quality of doctors’ documentation of children admitted into Emergency Paediatrics Unit (EPU), Usmanu Danfodiyo University Teaching Hospital (UDUTH). A 3-month cross-sectional study of admission records by different cadre of doctors for children admitted into the EPU between March and May 2016. A checklist was used to assess the quality of documentation. Data was analysed with SPSS version 22. Of the 191 patients’ clerking studied, 63 (33%) indicated the doctors’ cadre. The patients’ name written on the first page in 168 (88%), but only 31 (16.2%) indicated name on subsequent pages. Date and time of consultation were written in 183 (95.8%) and 61 (31.9%) respectively. Writing was legible in (174) 91.1%, with counter-signing of cancellations in 19 (9.9%). Examination findings documented included blood pressure in 18 (9.4%), pulse rate in 179 (93.7%), respiratory rate in 179 (93.7%) and temperature in 184 (96.3%). This study demonstrates the need for improvement in quality of paediatrics emergency documentation. Continuing medical education (CME) on this is essential. Key words: Quality, admission, documentation, emergency, paediatrics, Sokoto.
查看原文
分享 分享
微信好友 朋友圈 QQ好友 复制链接
本刊更多论文
住院记录的质量:对尼日利亚一家三级医院儿科急诊科的研究
医疗文件除了是一种法律和研究工具外,对于提供高质量的病人护理至关重要。在尼日利亚,没有形式的手写文件是常态。我们评估了乌斯马努丹福迪约大学教学医院儿科急诊科(EPU)收治儿童的医生记录的质量。对2016年3月至5月EPU收治儿童的不同骨干医生的住院记录进行为期3个月的横断面研究。使用检查表来评估文件的质量。数据分析采用SPSS version 22。在所研究的191例患者中,63例(33%)为医生干部。168例(88%)患者的名字写在第一页,但只有31例(16.2%)患者的名字写在后续页。183例(95.8%)和61例(31.9%)分别填写咨询日期和时间。其中(174)的文字清晰可辨,占91.1%,其中19(9.9%)有会签取消。记录的检查结果包括18例血压(9.4%)、179例脉搏(93.7%)、179例呼吸(93.7%)和184例体温(96.3%)。本研究表明需要提高儿科急诊文件的质量。这方面的继续医学教育(CME)是必不可少的。关键词:质量,入院,文件,急诊,儿科,索科托。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
求助全文
约1分钟内获得全文 去求助
来源期刊
自引率
0.00%
发文量
0
期刊最新文献
Management of ruptured pseudoaneurysm of the right common carotid artery in a resource-limited setting (Case report) Correlation of body mass index (BMI) with hematological indices and procoagulants among people with obesity in Sapele, Southern Nigeria Pattern of refractive errors in persons with albinism in two states of North-Western Nigeria Evaluation of patients with palliative care needs presenting at the Emergency Department, University College Hospital, Ibadan, Nigeria Relationship between renal ultrasonographic, CD4 cell count and proteinuria findings in HIV infected adult patients in Jos, Nigeria
×
引用
GB/T 7714-2015
复制
MLA
复制
APA
复制
导出至
BibTeX EndNote RefMan NoteFirst NoteExpress
×
×
提示
您的信息不完整,为了账户安全,请先补充。
现在去补充
×
提示
您因"违规操作"
具体请查看互助需知
我知道了
×
提示
现在去查看 取消
×
提示
确定
0
微信
客服QQ
Book学术公众号 扫码关注我们
反馈
×
意见反馈
请填写您的意见或建议
请填写您的手机或邮箱
已复制链接
已复制链接
快去分享给好友吧!
我知道了
×
扫码分享
扫码分享
Book学术官方微信
Book学术文献互助
Book学术文献互助群
群 号:481959085
Book学术
文献互助 智能选刊 最新文献 互助须知 联系我们:info@booksci.cn
Book学术提供免费学术资源搜索服务,方便国内外学者检索中英文文献。致力于提供最便捷和优质的服务体验。
Copyright © 2023 Book学术 All rights reserved.
ghs 京公网安备 11010802042870号 京ICP备2023020795号-1