Impact of Timely Documentation on Healthcare Delivery System in Abubakar Tafawa Balewa University Teaching Hospital, Bauchi

  • Naomi Olorundare
  • Mudathir Qossim
  • Timothy Olorundare
Keywords: timeliness, documentation, healthcare, ATBUTH

Abstract

Inadequacy or lack of timely updating and recording of health-related information in medical records do occur in various healthcare settings, which can lead to several issues, which can compromise the quality and continuity of care. Timely documentation among clinical 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. The study aimed to investigate the impact of timely documentation on healthcare delivery system in Abubakar Tafawa Balewa University Teaching Hospital, Bauchi. Methods used are structured questionnaire of health professionals in ATBUTH with questions targeted in accordance with the specific objective of this study, the sampling technique employed was a random sampling which is a sub-group of people chosen by chance in a way that everyone has the chance of being selected. Two hundred questionnaires were distributed and one hundred and seventy-one retrieved personally. Results of the finding are: majority of respondents are male (57.9 %), the highest profession that responded is health information officer/technician (34.5%) and lowest is physiotherapist (2.9%), highest respondent years of experience is 1-10 years (59.1%). The highest respondents affirm that accuracy of documentation, easy accessibility of documentation, completeness of documentation, consistency of information in documentation, and timeliness of documentation have an impact on health care delivery in ATBUTH. From the study it was found that timeliness of documentation has an impact on healthcare delivery system in ATBUTH. At the end of the study it was concluded that timeliness of documentation is effective in healthcare delivery system. It is recommended that medical and clinical personnel should maintain the timeliness, accuracy, integrity, availability, and consistency of all clinical documentation.

References

Adeleke, I. T., Erinle, S. A., Ndana, A. M., Anamah, T. C., Ogundele, O. A., et al. (2014). Health Information Technology in Nigeria: Stakeholders’ Perspectives of Nationwide Implementations and Meaningful Use of the Emerging Technology in the Most Populous Black Nation. American Journal of Health Research, 3(1-1), 17-24. https://doi.org/10.11648/j.ajhr.s.2015030101.13
Blake-Mowatt, C., Lindo, J. L., & Bennett, J. (2013). Evaluation of registered nurses' knowledge and practice of documentation at a Jamaican hospital. International Nursing Review, 60(3), 328–334. https://doi.org/10.1111/inr.12040
Bozeman, T.E., Harvey, K., Jarrell, I., Jones, W., Kock, K. et al. (2017). The development and implementation of a computer-based patient record in a rural integrated health system. Proceedings of the 3rd Annual Nicholas E. Davies CPR Recognition Symposium. Chicago: Health Information Management Systems Society.
Daller. (2022). Effective documentation. Impact of space and equipment.
Haque, W., Horvat, D. & Verhelst, L. (2014). A secure mobile platform integrated with electronic medical records. Prince George BC, Canada: University of Northern British Columbia.
Jasemi, M., Zamanzadeh, V., Rahmani, A., Mohajjel, A., & Alsadathoseini, F. (2013). Knowledge and Practice of Tabriz Teaching Hospitals’ Nurses Regarding Nursing Documentation. Thrita J Med Sci., 1(4) 133-8. https://doi.org/10.5812/thrita.8023
Karp, D., Huerta, J.M., Dobbs, C. A., Dukes, D., & Kenady, K. (2015). Medical Record Documentation for Patient Safety. MIEC. http://www.miec.com/Portals/0/pubs/MedicalRe c.pdf
Kumar, Y. M., Putul, M., & Rituraj, C. (2014). Medical Law and Ethics. In P. Mahanta (Ed.), Modern Textbook of Forensic Medicine and Toxicology (1st ed., pp. 21-64). New Delhi: Jaypee Brothers Medical Publishers (P) Ltd.
Lau, H. S., Florax, C., Porsius, A. J., & De Boer, A. (2000). The completeness of medication histories in hospital medical records of patients admitted to general internal medicine wards. British Journal of Clinical Pharmacology, 49(6), 597–603. https://doi.org/10.1046/j.1365-2125.2000.00204.x
Maroofi, F. (2016). Examine the Relationship between Hospital Information Systems and Improving Accountability of Nurses. International Journal of Asian Social Science, 6(5), 272–279. https://doi.org/10.18488/journal.1/2016.6.5/1.5.272.279
Mogli, G.D. (2019). Medical Records Role in Healthcare Delivery in 21st Century. Acta Informatica Medica, 17(4), 209-212.
Nyamtema, A.S. (2020). Bridging the gaps in the Health Management Information System in the context of a changing health sector. BMC Medical Informatics Decision Making, 10, 36. https://doi.org/10.1186/1472-6947-10-36
Taiye, B. H. (2015). Knowledge and practice of documentation among nurses in Ahmadu Bello University Teaching Hospital. IOSR J Nurs Health Sci. (IOSRJNHS), 4(6), 1–6.
Tang, P. C., LaRosa, M. P., & Gorden, S. M. (1999). Use of computer-based records, completeness of documentation, and appropriateness of documented clinical decisions. Journal of the American Medical Informatics Association: JAMIA, 6(3), 245–251. https://doi.org/10.1136/jamia.1999.0060245
WHO. (2017). Guidelines for Medical Record and Clinical Documentation. SEARO.
Published
2024-03-25
How to Cite
Olorundare, N., Qossim, M., & Olorundare, T. (2024). Impact of Timely Documentation on Healthcare Delivery System in Abubakar Tafawa Balewa University Teaching Hospital, Bauchi. European Journal of Science, Innovation and Technology, 4(2), 13-25. Retrieved from https://ejsit-journal.com/index.php/ejsit/article/view/395
Section
Articles