The Factors Militating Against Effective Documentation in Health Delivery System; A Case Study of Lagos State Teaching Hospital
Chapter One
OBJECTIVES OF THE STUDY
The Main Objective of the study is to appraise the factors militating against effective documentation in health delivery system. A case study of Lagos state teaching hospital; The specific objectives include:
- To find out if there are proper documentations of health delivery system in Lagos State Teaching hospital.
- To investigate the impacts of effective documentation of health delivery system in Lagos State Teaching Hospital.
- To identify the factors militating against effective documentation of health delivery system in Lagos state teaching hospital.
CHAPTER TWO
REVIEW OF RELATED LITERATURE
Hospitals deal with the life and health of their patients. Good medical care relies on well-trained doctors and nurses and on high-quality facilities and equipment. Without accurate, comprehensive up-to-date and accessible medical records, medical personnel may not offer the best treatment or may in fact misdiagnose a condition, which can have serious consequences. Associated records, such as X-rays, specimens, drug records and patient registers, must also be well managed if the patient is to be protected. Similarly, good medical records care ensures the hospital’s administration runs smoothly: unneeded records to be transferred or destroyed regularly by keeping storage areas clear and accessible; and key records to be found quickly by saving time and resources.
The medical record is the who, what, why, where, when and how of the patient care during hospitalization” (Huffman, 2001) Medical record is the only history of achievement, the only measurement of work being done by the medical and nursing staff, the only record of progress of the patient, and it is the source of information for many purposes. Taking into consideration the benefits of medical records, this paper systematically discusses the concept, significance and challenges of medical records as whole.
Concept of Records
Record is a set of data relating to single individual or item. It is also referred to as any instance of a physical medium on which information was put for the purpose of preserving it and making it available for future reference (Tumba, 2013).
Records can also be seen as a recorded information, regardless of medium or characteristics, made or received by an organization in pursuance of legal obligation or in the transaction of business (Wikipedia, June, 2013).
The Information Science Organization (ISO) defines records as “information created, received, and maintained as evidence and information by an organization or person, in pursuance of legal obligations or the transaction of business”. The Information Council on Archives (ICA) committee on Electronic Records defines a record as “recorded information produced or received in the initiation, conduct or completion of an institutional or individual activity and that comprises content, context and structure sufficient to provide evidence of the activity (Record Management Glossary, 2013).
CONCEPT AND TYPES OF MEDICAL RECORDS
It is widely known that the quantities of data and information generated increase every day, especially in the healthcare sector. The population growth, the increasing number of patients and the emergence of new diseases and symptoms require healthcare organizations to capture and manage enormous amounts of data and information (Desouza, 2005). Records form an integral part of any medical practice because they help to ensure good care for patients and also become critical in any future dispute or investigation.
Haux (2006) defined medical record as a “confidential record that is kept for each patient by a healthcare professional or organization. It contains the patient’s personal details (such as name, address, date of birth), a summary of the patient’s medical history, and documentation of each event, including symptoms, diagnosis, treatment and outcome. Relevant documents and correspondence are also included.
CHAPTER THREE
RESEARCH METHODOLOGY
INTRODUCTION
In this chapter, we described the research procedure for this study. A research methodology is a research process adopted or employed to systematically and scientifically present the results of a study to the research audience viz. a vis, the study beneficiaries.
RESEARCH DESIGN
Research designs are perceived to be an overall strategy adopted by the researcher whereby different components of the study are integrated in a logical manner to effectively address a research problem. In this study, the researcher employed the survey research design. This is due to the nature of the study whereby the opinion and views of people are sampled. According to Singleton & Straits, (2009), Survey research can use quantitative research strategies (e.g., using questionnaires with numerically rated items), qualitative research strategies (e.g., using open-ended questions), or both strategies (i.e., mixed methods). As it is often used to describe and explore human behaviour, surveys are therefore frequently used in social and psychological research.
POPULATION OF THE STUDY
According to Udoyen (2019), a study population is a group of elements or individuals as the case may be, who share similar characteristics. These similar features can include location, gender, age, sex or specific interest. The emphasis on study population is that it constitute of individuals or elements that are homogeneous in description.
This study was carried out to examine the The Factors Militating Against Effective Documentation In Health Delivery System. Lagos State Teaching Hospital form the population of the study.
CHAPTER FOUR
DATA PRESENTATION AND ANALYSIS
This chapter presents the analysis of data derived through the questionnaire and key informant interview administered on the respondents in the study area. The analysis and interpretation were derived from the findings of the study. The data analysis depicts the simple frequency and percentage of the respondents as well as interpretation of the information gathered. A total of hundred and twenty (120) questionnaires were administered to respondents of which 100 were returned. The analysis of this study is based on the number returned.
CHAPTER FIVE
SUMMARY, CONCLUSIONS AND RECOMMENDATIONS:
Introduction
This chapter summarizes the findings on The Factors Militating Against Effective Documentation In Health Delivery System. A Case Study Of Lagos State Teaching Hospital. The chapter consists of summary of the study, conclusions, and recommendations.
Summary of the Study
In this study, our focus was on The Factors Militating Against Effective Documentation In Health Delivery System. A Case Study Of Lagos State Teaching Hospital. The study is was specifically focused on examining if there are proper documentations of health delivery system in Lagos State Teaching hospital; investigating the impacts of effective documentation of health delivery system in Lagos State Teaching Hospital and identifying the factors militating against effective documentation of health delivery system in Lagos state teaching hospital..
The study adopted the survey research design and randomly enrolled participants in the study. A total of 100 responses were validated from the enrolled participants where all respondent are staff of Lagos state teaching hospital, Lagos State.
Conclusions
With respect to the analysis and the findings of this study, the following conclusions emerged;
Based on the findings of this research work, it was concluded that inadequate funding and resources is the main factor militating against effective MRD in LASUTH. Government should make provision for more facilities and electronic medical record equipment to enhance efficient MRD while also making effort to employ more Health Information professionals to further boost effective MRD in LASUTH.
Recommendation
The following recommendations were made, based on the findings of this study.
- The hospital should devote a substantial budget to technological development annually for maintenance of equipment and infrastructure in the hospital.
- Policies, strategies and decisions to positively support and guide the proper implementation and usage of manual record management system should be upheld and considered very important in the hospital system.
- Adequate provision should be made for alternative power supply to solve the problem of erratic power supply which makes accessibility to the electronic record difficult for the medical staff.
- The dearth of unskilled staff in ICT should be urgently addressed. Periodic staff training should be organized for the medical staff to improve their ICT skills and make them relevant in the present day technological-driven health care delivery.
REFERENCES
- Personal Health Records. CMS. April 2011. [cited 2015September 22].
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- Law and Physician Homepage. Medical Records inLitigation. [cited 2015 Sept 21]; Available from: URL:http://biotech.law.lsu.edu/Books/lbb/x187.htm [4]. Deepender Deswal, TNN. The Times of India.
- Haryanadoctors doctor ‘legal’ reports 2010 Dec 6; [cited 2015 September 23]; Available from: URL:http://timesofindia.indiatimes.com/india/Haryan a-doctors-doctor-legal- reports/articleshow/7050516.cms
- Thaindian News. Doctor jailed for issuing fake medicalcertificates. 2008 December 6 by IANS [cited 2015 July4]; Available from: URL:http://www.thaindian.com/newsportal/uncategor ized/doctor-jailed-for-issuing-fake-medical- certificates_100127982.html
