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 Home»Health Information Management» An evaluation of the quality of health records documentation and its utilization during legal procedures (case study of Nnamdi Azikiwe University Teaching Hospital Nnewi)

An evaluation of the quality of health records documentation and its utilization during legal procedures (case study of Nnamdi Azikiwe University Teaching Hospital Nnewi)

 Department: Health Information Management  
 By: usericon godstimearinze  

 Project ID: 7582
   Rating:  (5.0) votes: 1
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   Price:₦4000
Abstract
Accurate medical records documentation is crucial for providing high-quality healthcare services. Proper documentation ensures clear communication among healthcare providers, supports accurate diagnoses and treatments and serves as a legal record. However, poor and improper documentation by healthcare professionals has become a persistent issue, leading to ineffective and inadequate patient care. Failure to properly document can result in unclear diagnostic studies, incorrect treatment decisions, and further health complications. This study aimed to identify practices to improve medical records documentation and examine reasons for improper documentation. Four research questions were raised, and two hypotheses were postulated. A descriptive study design with a simple random sampling technique was employed. From a population of 897 in a selected hospital department, a sample of 273 respondents was drawn. Data were collected via questionnaires and analyzed using simple percentages and frequency distribution tables. The findings revealed that 67% of respondents affirmed the critical role of good medical records documentation in delivering healthcare services and as evidence in legal proceedings. Additionally, 61% agreed that ensuring confidentiality is essential for continuity of care. However, 73% were unaware of the uses of medical records in medico-legal cases. In conclusion, the study aimed to educate healthcare providers on the importance of excellence in medical records documentation, as it reflects and creates excellence in medical care. The principle"if it''s not documented, it didn''t happen" underscores the significance of proper documentation. Failure to document tests, patient conversations, or consultations with other providers can be presumed as events that never occurred, potentially affecting legal admissibility in court trials....
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