[ad_1]
Introduction
In routine healthcare practice, evidence about the care and treatment of patients, progress notes, assessments and care plans,1 laboratory tests and results, medication and drug prescription information, patient education and counselling2 are some of the routine practices of health professionals. Therefore, documenting the health professionals’ routine practices are important for various purposes.
Documentation is a standard way of keeping ongoing patient care information. It is the relevant facts of routine health information and patient care plans,3 such as professionals’ evaluation and judgement about the patients, evaluation charts, tests, reports, subjective notes or professionals’ reflections.4
Documenting routine practices is essential for the continuity of patient care, legal defence, reimbursement, communication among healthcare professionals and better patient diagnoses and treatments.5 Maintaining routine practice is part of the health professional obligation. Healthcare facilities’ by-laws or policies should require health professionals to complete patient records.6 Whether the documentation is a paper-based or electronic system, it should be patient-focused, accurate, relevant, clear, permanent, confidential and timely. Electronic patient record systems are better for reducing the time spent on documenting patient information and enhancing the quality of documentation.7
Poor documentation practice affects patient management, continuity of patient care and medicolegal issues, which arise from incomplete and inadequate documentation, lack of accuracy and poor quality.8 It leads to adverse patient outcomes, medication errors and patient deaths.9 Distorted health information may influence health professionals’ decision-making capabilities due to inappropriate and misleading documentation practices.10
Globally, poor communication between health professionals is a reason for medical error and patient mortality.9 Many health professionals’ documentation practice is incomplete, inaccurate and of poor quality. According to evidence from the USA, documentation errors are a cause of at least one death and 1.3 million injuries annually.11 Moreover, health professionals’ documentation practice is inadequate such as 33.3% in Indonesia,12 47% in England13 and 50% in Iran.14
In the low-income and middle-income regions, a qualitative study undertaken in Uganda stated that documentation practice is limited by constraints and poor support from the administration.15 In Ghana, 46% of care is provided, and progress notes are not documented after the first day of patient admission.16 In Nigeria, only 44% of health professionals had good documentation knowledge and practice.17
In Ethiopia, documentation is poorly practised and has been reported as being left undone.3 Health professionals’ documentation practice is 47.8% in the Tigray18 and 37.4%3 in Amhara regions. Surprisingly, 88% of the medication provided has been wrongly documented.19 A study report in the Amhara region states that 87% of the medications had documentation errors.19
Age, sex, experience, income, levels of education, health professionals’ knowledge and attitude,3 12 18 motivation, workload and training about documentation20 are factors associated with routine practice documentation.
Documenting health professionals’ routine activities is valuable for sharing knowledge and learning from history. This has a significant impact on better decision-making and accuracy in patient diagnosis and treatment. As per our literature review, studies have not been undertaken in the current study setting. Few studies in similar settings have been carried out with only nursing as a study participants, education and counselling given to the patient were not assessed. So, assessment documentation practice in both medical and non-medical practices, including all health professionals is crucial. Therefore, this study aimed to determine health professionals’ routine practice documentation and associated factors.
[ad_2]
Source link
