Influence of clinical documentation on patients record management at Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra state Department: Health Information Management By: Godstimearinze Project ID: 7507 Rating: (5.0) votes: 1Rate this project12345 Price:₦3000 Get the Complete MaterialAbstractProper documentation of medical records promotes patients’ and physicians’ best interests for many reasons. Recording all relevant data of a patient’s care helps physicians monitor what is been done, and curtails the risk of mistakes scrambling into the treatment process. However, despite these benefits, most hospital physicians, nurses, health information managers and other healthcare professionals in the country today do not ensure accurate clinical documentation, as a result of a lack of trained personnel who are not formally trained in the proper clinical documentation practice by their predecessors. Therefore, the study examines the influence of clinical documentation on patients’ record management. A descriptive study was conducted among 50 healthcare professionals (doctors, nurses and health information managers) working in General Outpatient Department, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra state. The data for the study was collected using a structured, self-administered, questionnaire, were computed in a table and analyzed using simple percentage and frequency counts. The finding observed that there are factors affecting good clinical documentation such as untrained personnel and illegible handwriting of healthcare professionals (especially doctors). The reasons why clinical documentation is needful and important in the treatment of patients as indicated by the majority of the respondents include ensuring quality care is rendered to the patient and that medical records form an important part of the management of a patient. Adequate clinical documentation is necessary to ensure quality care. Inadequate clinical documentation which occurs due to poor documentation impacts both patient care and outcomes. This study calls upon industry, government, and academic leaders to acknowledge the many contributions of Health Information Managers and address the potential shortages of these professionals. ...Preview Download Preview +Other Health Information Management project topics and materials you might be interested in»Analysis of filing system and consequences of misfiling»Evaluation of the problems and constraints facing health record keeping and professionals»Impact of health information management in healthcare delivery»Assessment of challenges of health information management practice in General Hospital Ilorin, Kwara State»Analysis of filing system and consequences of misfiling patients health records in University of Ilorin Teaching Hospital, Kwara state»A study into causes of misfiling among health information management professionals in health records department - case study of University of Ilorin Teaching Hospital, Kwara state»Evaluation of confidentiality of patient health records among hospital staff»Factors militating against effective documentation in health care delivery system in University of Benin Teaching Hospital Benin City, Edo state»Effect of lack of health information computerization in the primary health care system»Evaluation of patient appointment system - a case study of university of Ilorin teaching hospital»Causes and consequences of breach of confidentiality of patient health information in Lagos University Teaching Hospital, Lagos state»Impact of health statistics in the health care delivery system at University of Ilorin Teaching Hospital, Ilorin, Kwara State»Impact of electronic medical records on patients waiting time in health care delivery system in Federal Medical Center, Asaba, Delta state»Evaluation of the importance of health information management in primary health care»Knowledge and perception of health information management professionals on electronic coding for quality clinical data in University of Ilorin Teaching Hospital, Ilorin, Kwara state