A STUDY OF MEDICAL RECORDS DOCUMENTATION ISSUES IN FEDERAL NEUROPSYCHIATRIC HOSPITAL ENUGU WITH SPECIAL REFERENCE TO DISCHARGE FOLLOW UP

Table of Contents

Introduction - - - - - - - - - - 4

Chapter One: The Incidence of poor documentation - - - 5

1.1 Absence of Biometric Registration for Patients - - - - 5

1.2 Absence of Ehr Software & Library database - - - - 5

1.3 Absence of Admissions Register - - - - - - 6

1.4 Absence of Admission and Discharges unit - - - - 6

1.5 Absence of Coding and Indexing unit - - - - - 7

1.6 Absence of Statistics unit - - - - - - - 7

1.7 Absence of Discharge Summaries - - - - - - 7

Chapter Two: Cause of Poor Documentation and Absence of Discharge

Summaries - - - - - - - - - - 9

2.1 Poor Stress Management - - - - - - - 9

2.2 Sub optimal use of office space - - - - - - 9

2.3 Psychodynamic Hazards - - - - - - - 9

2.4 Consumer Preferential bias - - - - - - - 9

2.5 Occupational undue influences - - - - - - 10

2.6 Psychosocial Dynamics - - - - - - - 10

Chapter Three: Implications and Mitigation of Poor Documentary and

Absence of Discharge Summaries - - - - - - 11

3.1 Documentation inconsistencies and lapses - - - - 11

3.2 Loss of Data - - - - - - - - - 11

3.3 Negligence - - - - - - - - - 12

3.4 Poor or Distorted Social Responsibility - - - - - 14

3.5 Accumulation of Internal debts - - - - - - 14

3.6 Lack of Perfect closure - - - - - - - 14

Chapter Four: Suggestions for improvement and conclusion - - 16

4.1 Illustration One - - - - - - - - 16

4.2 Illustration Two - - - - - - - - 16

4.3 Illustration Three - - - - - - - - 17

4.4 Illustration Four - - - - - - - 17

4.5 Illustration Five - - - - - - - - 17

4.6 Illustration Six - - - - - - - - 17

4.7 Illustration Seven - - - - - - - - 19

4.8 Illustration Eight - - - - - - - - 20

4.9 Illustration Nine - - - - - - - - 22

4.9.9 Illustration Ten - - - - - - - - 24

4.9.9.0 Illustration Eleven - - - - - - - 26

4.9.9.1 Illustration Twelve- - - - - - - 28

4.9.9.2 Illustration Thirteen- - - - - - - 29

5.0 Conclusion - - - - - - - - 30

5.1 Bibliography - - - - - - - 31

 Abstract

The medical records department is best regarded as the heart of the hospital. In that order of due respect an idealistic observation must be made with a view to detecting medical record flows, data entry errors and ambiguous hospital process checks. From first entry to the last appointment every patient has a medical record that is usually detailed in diagnostic and investigations histories, bio-data and correspondences.

The normality of the records generated becomes the query borne in this work against a standard that can be theorized or comparatively reduced. However, the working status must be succinctly assessed for effectiveness and efficiency by and large.

Chapter One

1.0 The Incidence of Poor Documentation

Manual medical records usually have demerits of physical carriage, legibility, wear and tear and cost of stationeries supplies. However, from an idealistic standpoint there are many flaws which would take a careful administrative appeal to clear thus:

i. Absence of biometric registration for patients

ii. Absence of electronic Health records software and library/database.

iii. Absence of admissions registers.

iv. Absence of Admission and discharges unit

v. Absence of coding and indexing unit

vi. Absence of statistics unit

vii. Absence of discharge summaries

1.1 Absence of Biometric Registration For Patients

The biometric registration system which has so far worked in the banking sector as biometric verification number BVN is a system process that can check patients� information. This check is usually for validity and veracity and enhances the responsibility status required of both patient and hospital. Subtle issues like distance and remoteness of location can be narrowed using biometrically identified cities, towns, villages, countries, communities and kindreds. These enhance civic checks on all patient entries usually automatically during registration of new visit/call/entry or appointment.

1.2 Absence of Electronic Health Records software and library/database

There are both vendor Ehr softwares and customized Ehr softwares. Vendor Ehr are usually procured online via the internet with subscriptions renewed periodically like monthly, bi-monthly, annually or bi-annually. Such software include Prognosis, NueMD, TotalMD, software are built to the specifications of the hospital facility as well as observing the international standards of netiquette required for safe and peaceful operation. Such software are currently in use in Annunciation Specialist Hospital Enugu, Niger Foundation Hospital and Diagnostic Centre Enugu and Lagoon Hospitals Network Lagos, Nigeria.

1.3 Absence of Admissions Register

The admission process is a critical collectively bargained entry into a hospital ward (emergency or intensive care unit) for the purposes of treatment on a short or long term basis. This process therefore needs the feedback and feed forward processes to ensure optimal safety of the patient. Tools like the Admissions Slip, the admissions registers and the daily ward statements are veritable tools which a hospital going concern needs to check window entries and sharp practices. The clinical add-ons like the ward care givers will also be given a succinct check from excesses like over carriage or over loaded carriages, peddling or hawking of drugs and patients belongings, over-indulgence of personal selling and manipulation of hospital clinical system. Consequently, these three tools when neglected i.e. (Admission slips, admissions register and daily ward statements) can lead to gross licentiousness by hospital staff and patients alike. Other tools that may be applied as process checks include, the patient consent forms, the admissions declination form and the DAMA (Discharged Against Medical Advice) form. Even though the later forms have pre-conditions of admission by a doctor, acceptance and signing of the consent forms, entry into the ward and allocation of bed space, signing of the declination forms, deduction of objection or points of discomfort, signing of DAMA discharge against medical advice forms. The integrity of the hospital should not be compromised neither should the right of the patient be abused as contained in the Patient�s Bill of Right 2018 or Hospital Rights and Responsibilities 2018.

1.4 Absence of Admissions and Discharge Unit

This unit a mandatory component of the medical records department and deserves allocation of office space and medical records staff. The co-ordination of the six forms and registers mentioned above thus: Admissions slip, Admissions register, Daily ward Statements, the consent forms, the declination forms and the DAMA form become the office retinue of the admissions and discharges unit of the medical records department. This unit takes into cognizance all regular admissions and discharges. Regularizes emergency entries and The Good Samaritan fences, documents unwholesome discharges i.e. gate crashes and abscondments.

1.5 Absence of Coding and Indexing Unit

The coding and indexing is more of a medical generosity in detailed description of diseased conditions, diseases and circumstances surrounding health facilities and staff. This generosity becomes a ready reckoner to any research fellow or health professional in need of vital information. When this attribute of the medical records department is not effective, efficient or totally absent, the generosity disappears. The public relations motive begins to be biased into areas of over obvious functional utility especially in physical health care terms. Interestingly, the card processing and folders� carriage becomes the attribute that holds sway in this bias happenstance.

1.6 Absence of Statistics Unit

Statistics is a global utility that is needed for both econometric and medical analysis. The implication of strategic planning, monitoring and evaluation as well as corporate organization lies in availability of adequate statistical values in all required areas. Data capturing and documentation makes better sense with statistical evaluation with time series analyses and active identification of normalities, morbidities, mortalities and other subtle hospital statistics. The wholesomeness of a hospital environment is determined by statistical accuracy, tolerance, prudence and historical relevance.

1.7 Absence of Discharge Summaries

Arora et al (2010) found that primary care physicians (PCPs) are often unaware of their patient�s hospital admission. Older patients whose PCPs were unaware of their hospitalization were more likely to experience at least one post-discharge problem, which was complicated by a lack of communication between hospitals and PCPs. If the PCPs awareness were to be accepted as transferable to the medical records department it translates into a myriad of issues amongst which negligence stands prominent.

Le Doare et al (2009) relates that a retrospective study of patient referral letters and paired discharge summaries for all patients admitted to a hospital following referral by their G.P. Results showed that 58% of the patients� referral letter to the accident and emergency department were missing from the medical record. This means that some services may have been declined or neglected due factors best known to the bearers.

The absence of the discharge summary betrays parity of authority and responsibility, as well as the generosity that makes medical practice worth the call as life saving