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
   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....
Preview +
Other Health Information Management project topics and materials you might be interested in
»Analysis of filing system and consequences of misfiling
»Impact of health information management in healthcare delivery
»Evaluation of the problems and constraints facing health record keeping and professionals
»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
»Factors militating against effective documentation in health care delivery system in University of Benin Teaching Hospital Benin City, Edo state
»Evaluation of confidentiality of patient health records among hospital staff
»Evaluation of patient appointment system - a case study of university of Ilorin teaching hospital
»Effect of lack of health information computerization in the primary health care system
»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
»Evaluation of the importance of health information management in primary health care
»Impact of electronic medical records on patients waiting time in health care delivery system in Federal Medical Center, Asaba, Delta state
»Knowledge and perception of health information management professionals on electronic coding for quality clinical data in University of Ilorin Teaching Hospital, Ilorin, Kwara state

Departments

UPLOAD A PROJECT

Do you have project materials and source code to share? Upload and earn with it.