Documented records are veritable tool for good health care management. Their reliance depends on accurate, prompt and proper documentation of the care provided and periodic analysis of such data. This study centered on available records at the General Hospital, Ijadoga, Otukpa, A review of existing information was carried out to assess the documentation of 357 paper-based health records of inpatients discharged in 2014. 357 patient records were reviewed from the Out Patients department(OPD) (45.90%), Female Ward (24.32%), and other specialties (29.78%). Record keeping was very good (98.49%) for promptness recording care within the first 24 hours of admission, fair (58.80%) for proper entry of patient unit number (unique identifier), and very poor (12.84%) for utilization of discharge summary forms. Overall, surgery records were nearly always (100%) prompt regarding care documentation, Out Patients department(OPD) were followed a regular pattern (80.65%) in entering the vitals of patients and consultations/ examinations with/of Doctors/Nurses was properly done (100%).Of all (62.02%) folders were alphabetically/chronologically arranged, (62.29%) were properly held together with file tags, and most (80.60%) discharged folders reviewed, analyzed and appropriate code numbers were assigned. Some short comings on the part of administrative staff in charge of record keeping were noted. Some of the entries were properly done which shows that some of the hospital staff know what to do but the zeal to do it was not there. Findings indicates that further training is very necessary for better performance.
Keywords : Medical coding, software, data quality, discharge summary, quality assurance, Clinical documentation, electronic medical records, patients’ health records, medical informatics.