Quality of hospital admission documentation: A study in an emergency paediatric unit of a tertiary hospital in Nigeria

Abstract

Medical documentation, in addition to being a legal and research tool, is vital in providing quality patient care. In Nigeria, hand written documentation without proforma, is the norm. We assessed the quality of doctors’ documentation of children admitted into Emergency Paediatrics Unit (EPU), Usmanu Danfodiyo University Teaching Hospital (UDUTH). A 3-month cross-sectional study of admission records by different cadre of doctors for children admitted into the EPU between March and May 2016. A checklist was used to assess the quality of documentation. Data was analysed with SPSS version 22. Of the 191 patients’ clerking studied, 63 (33%) indicated the doctors’ cadre. The patients’ name written on the first page in 168 (88%), but only 31 (16.2%) indicated name on subsequent pages. Date and time of consultation were written in 183 (95.8%) and 61 (31.9%) respectively. Writing was legible in (174) 91.1%, with counter-signing of cancellations in 19 (9.9%). Examination findings documented included blood pressure in 18 (9.4%), pulse rate in 179 (93.7%), respiratory rate in 179 (93.7%) and temperature in 184 (96.3%). This study demonstrates the need for improvement in quality of paediatrics emergency documentation. Continuing medical education (CME) on this is essential. Key words: Quality, admission, documentation, emergency, paediatrics, Sokoto.