Importance of Effective Clinical Documentation by Medical Doctors to Patient Care Management in Federal Teaching Hospital, `Ido Ekiti, Ekiti State, Nigeria


Authors : Ogbona Mary Aina; Ayodele Kolawole Musa; Ojo Phebian Opeyemi

Volume/Issue : Volume 5 - 2020, Issue 7 - July

Google Scholar : http://bitly.ws/9nMw

Scribd : https://bit.ly/2WWENvm

DOI : 10.38124/IJISRT20JUL264

Abstract : This study scrutinized clinical documentation by medical doctors as a factor affecting patient care management and goes a long way to determine the quality of care given to patients in Federal Teaching Hospital, Ido - Ekiti Nigeria. The study adopted descriptive survey research design by administering questionnaire to respondents. The result disclosed that larger percentage of respondents agreed that the objectives of clinical documentation in patient care management are to acquiesce with legal regulatory and institutional requirements that will assure compliance with clinical documentation Moreover, the result shows that, greater number of the doctors consented that adherence to policy procedure with maen=1.80 and SD=0.45 is the level of blunders that are the most practised in clinical documention guideline/standard in the health institution ,while those that are less practised in the health institutions are medical history, medical follow up, drug administration and proper diagnosis with (×=1.40, SD=0.55). It was also discovered from the result that the use of clinical documentation aids in continuity of evaluation of patient 95.5%, the use of accurate clinical documentation can help reduce errors 95.4%. Majority of respondents agreed that, the use of clinical documentation provides a basis for follow-up.In addition, the result signifies that the most areas of blunders in clinical documentation in the health institutions are of disparaging remarks with mean of 2.80 and SD=0.45.Lastly, the result points out that the perception of clinical documentation has a temperate significant relationship with patient care management N=450, r=.363**, p <.05. This implies that the level of doctor's perceptions of clinical documentation have the propensity to increase the level of patient care management in the health institution.

Keywords : Clinical Documentation; Health Care; Medical Records; Physicians; Patient Care; Management; Nigeria.

This study scrutinized clinical documentation by medical doctors as a factor affecting patient care management and goes a long way to determine the quality of care given to patients in Federal Teaching Hospital, Ido - Ekiti Nigeria. The study adopted descriptive survey research design by administering questionnaire to respondents. The result disclosed that larger percentage of respondents agreed that the objectives of clinical documentation in patient care management are to acquiesce with legal regulatory and institutional requirements that will assure compliance with clinical documentation Moreover, the result shows that, greater number of the doctors consented that adherence to policy procedure with maen=1.80 and SD=0.45 is the level of blunders that are the most practised in clinical documention guideline/standard in the health institution ,while those that are less practised in the health institutions are medical history, medical follow up, drug administration and proper diagnosis with (×=1.40, SD=0.55). It was also discovered from the result that the use of clinical documentation aids in continuity of evaluation of patient 95.5%, the use of accurate clinical documentation can help reduce errors 95.4%. Majority of respondents agreed that, the use of clinical documentation provides a basis for follow-up.In addition, the result signifies that the most areas of blunders in clinical documentation in the health institutions are of disparaging remarks with mean of 2.80 and SD=0.45.Lastly, the result points out that the perception of clinical documentation has a temperate significant relationship with patient care management N=450, r=.363**, p <.05. This implies that the level of doctor's perceptions of clinical documentation have the propensity to increase the level of patient care management in the health institution.

Keywords : Clinical Documentation; Health Care; Medical Records; Physicians; Patient Care; Management; Nigeria.

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