Assessment of Documentation Accuracy and Adequancy Among Healthcare Providers in University College Hospital Ibadan

The study assessed documentation accuracy and adequancy among healthcare providers in university college hospital ibadan
Documentation refers to the process of recording, organizing and maintaining accurate , comprehensive and up-to-date information about a patient's medical history, treatment plans, diagnoses, procedures, and other clinical data. Accurate and adequate documentation is crucial in healthcare services, particularly in tertiary institutions like University College Hospital (UCH), it serves as a permanent record of patient care, allowing healthcare providers to track patient progress, make informed decisions, and evaluate treatment effectiveness (World Health Organization, 2019). Poor documentation can lead to miscommunication, medical errors, and compromised patient safety and this issues that can leads to medical errors ,diagnostic delays , inadequate treatment , increased healthcare cost and legal regulatory risk . This study was carried out to assess the documentation accuracy and adequacy among healthcare providers.A descriptive research design was adopted In assessing documentation accuracy and adequacy among healthcare providers in University College Hospital Ibadan and the respondents were selected using multi staged sampling techniques, stage one used purposive sampling to select Nurses, doctor and Health information managers because they are the main healthcare providers dealing with documentation ,Stage two used proportional sampling techniques to calculate the number of respondent from each unit of selected healthcare professional and stage three used convenience sampling to select healthcare providers. Data were collected using well- structured questionnaire and the Information gathered include socio demographic data ,level of documentation practice among healthcare providers, challenges faced by healthcare providers in maintaining accurate records and recommendations for improving documentation practices among Healthcare professionals. Data was analysed using SPSS Version 23 to determine the frequency, percentage,mean and standard deviation
The result showed that the majority of the respondent were nurses(50.7%) , doctor (45.7%) and health information management (3.6%) while (95.7%) of the respondent make use of paper based record to document patient information . It was found that Marjority of the respondent experienced time constraints (65.0%) when documenting patient information, (79.3%) experienced a situation where incomplete or inaccurate documentation affected patient care ,(80.7%) were often interrupted when documenting and (72.1%) have difficulty in accessing patient information due to documentation system limitations. To improve documentation practice , most of the respondent suggested that there is a need if regular training session (89.3%) , provision of resources and support (74.3%) , conduct regular documentation audits ( 83.6%) and integration of documentation system with other healthcare system (64.3%) would help to improve documentation practice among healthcare providers.It was concluded that most of the respondent felt that the documentation practice was unsatisfactory . It is therefore recommended that the healthcare facility should provide regular training session , onduct regular documentation audits to ensure compliance and healthcare facility should establish clear guidelines for documentation and fostering a collaborative environment among team member which can significally enhance clear and effective communication