title: Quality of documentation of urethral catheterization in a Nigerian teaching hospital.
abstract: BACKGROUND
  Urethral catheterization is a common minimally invasive procedure with well-known complications some of which may be severe. Quite often, a clinician is invited to manage the short and long-term complications of the procedure without adequate records of the procedure itself.
  
  
  OBJECTIVE
  This study aims to determine the quality of documentation of urethral catheterization in our health institution.
  
  
  METHODS
  This prospective study was carried out over a period of 1 month. The documentations in the medical notes and nursing records with respect to urethral catheterisation were assessed using 10 different parameters with the aid of a pro-forma. Statistical analysis was done with the Wilcoxon signed ranks test.
  
  
  RESULTS
  A total of 89 patients were catheterised in the wards, the emergency departments and the theatre. All the catheterizations were performed by doctors. The overall quality of documentation of catheterisation was poor: It was significantly worse in the medical notes than the nursing records with 28% of all cases documented by the nurses not documented by the physicians. Documentation in the theatre and emergency were worse, while there was no documentation of aseptic technique in any patient. An 11% incidence of complications was noted.
  
  
  CONCLUSIONS
  The quality of record keeping concerning urethral catheterization was inadequate. This is important not only for patients' care, but also for medico-legal purposes. We therefore recommend regular audit and introduction of protocols for proper documentation.
authors.affiliation: Urology Unit, Department of Surgery, College of Medicine, University of Lagos, Lagos State. habeeb_tijani@yahoo.com
authors.forename: K H
authors.initials: KH
authors.lastname: Tijani
authors.forename: A O
authors.initials: AO
authors.lastname: Lawal
authors.forename: R W
authors.initials: RW
authors.lastname: Ojewola
authors.forename: T A
authors.initials: TA
authors.lastname: Badmus
mesh_terms: D004282:Documentation / Q000379:methods* / Q000592:standards; D005260:Female; D006784:Hospitals, Teaching; D006801:Humans; D008297:Male; D008499:Medical Records / Q000592:standards*; D009549:Nigeria; D009737:Nursing Records / Q000592:standards*; D011446:Prospective Studies; D011785:Quality Assurance, Health Care; D014522:Urethral Diseases / Q000628:therapy*; D014546:Urinary Catheterization / Q000379:methods / Q000592:standards*