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.