Data quality assessment in healthcare: a 365-day chart review of inpatients' health records at a Nigerian tertiary hospital.
BACKGROUND
Health records are essential for good health care. Their quality depends on accurate and prompt documentation of the care provided and regular analysis of content. This study assessed the quantitative properties of inpatient health records at the Federal Medical Centre, Bida, Nigeria.


METHODS
A retrospective study was carried out to assess the documentation of 780 paper-based health records of inpatients discharged in 2009.


RESULTS
732 patient records were reviewed from the departments of obstetrics (45.90%), pediatrics (24.32%), and other specialties (29.78%). Documentation performance was very good (98.49%) for promptness recording care within the first 24 h 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, obstetrics records were consistent (80.65%) in entering patients' names in notes, and the principal diagnosis was properly documented in all (100%) completed discharge summary forms in medicine. 454 (62.02%) folders were chronologically arranged, 456 (62.29%) were properly held together with file tags, and most (80.60%) discharged folders reviewed, analyzed and appropriate code numbers were assigned.


CONCLUSIONS
Inadequacies were found in clinical documentation, especially gross underutilization of discharge summary forms. However, some forms were properly documented, suggesting that hospital healthcare providers possess the necessary skills for quality clinical documentation but lack the will. There is a need to institute a clinical documentation improvement program and promote quality clinical documentation among staff.
Department of Health Information, Federal Medical Centre, Bida, Nigeria. ibratadeleke_aliseyin@yahoo.com
Ibrahim Taiwo
IT
Adeleke
Adedeji Olugbenga
AO
Adekanye
Kayode Abiodun
KA
Onawola
Alaba George
AG
Okuku
Samuel Adebowale
SA
Adefemi
Sunday Adesubomi
SA
Erinle
AbdurRahman Alhaji
AA
Shehu
Olubunmi Edith
OE
Yahaya
AbdulLateef Adisa
AA
Adebisi
John Adeniran
JA
James
Oloundare Olanrewaju
OO
AbdulGhaney
Lateef Mosebolatan
LM
Ogundiran
Abdullahi Daniyan
AD
Jibril
Moses Esimy
ME
Atakere
Moses
M
Achinbee
Oluwaseun Ayoade
OA
Abodunrin
Muhammad Wasagi
MW
Hassan
D004282:Documentation / Q000592:standards*; D006801:Humans; D008330:Management Audit; D008499:Medical Records; D008511:Medicine; D009549:Nigeria; D010351:Patient Discharge; D011786:Quality Control; D015203:Reproducibility of Results; D062606:Tertiary Care Centers