Assessment of patient documentation and registration in emergency department in Tikrit Teaching Hospital.

Abstract

Patient   information,    medical    history,  clinical   outcomes     and   demographic      information, can   be  registered   in different  ways  in registration  programs.  Emergency   department records    are    important     source    of   injury  surveillance     data.     The  bedside     registration, combined    with a  new  electronic    medical    record   system,  helps  to expedite    patient   care in   the    emergency       department.       To  identify    the    registration     and    documentation performance      in emergency      unit  in Tikrit teaching     hospital   and   to  estimate    the  gap   in the  file system   registration.    This is a  cross-sectional     study   performed     by  collecting    and analysis   of  data    registered    on  files of  cases   admitted     to  the   emergency      unit  in Tikrit Teaching    Hospital  over  one  month   period   extended     from  1-31 January   2011  (including demographical     data,   examination,   lab  Investigation,  discharging   notes  and   doctor notes)   of  (2660)  records    these    information    was  divided    into  items  weighing    by  using scales  designed   according   the  data   registered  in the  records.   Current  study revealed that    most   of  the   demographic         information      were    not  fully  written    as   1560   (58.65%)   files did   not   meet    the   standards      of  documentation        while   patients     history   there    were 1500(56.4%)   files  with   partially    written   general      history.   (52.6%),   (60.2%)   not   written information    systematic    and    background      history  respectively.     The  study   founded     that examination    notes  there  were  a  high percentage      of incomplete    documentation      of vital signs,   general      assessment       and     systematic       examination        which     represented         (  70.7%   ) (65.41% ) and   (59.4%  ) respectively.    The sources   of referral  showed    (51.9%) were  walk-in patients   which  is the  most  common    source.   Most of files contain    discharging    note,   (40.6 %) were   discharged     home,   and   (39.1%) discharged     on  their  responsibility.   There  were (68.42%)  files contained     the   notes   of  the   house   officer.   Registration    of  files does   not meet    the   international      standards,       as  files are   packed      in nylon  sacs   and   stored    in the   unit of statistics.   Concerning    the  registration   book  of accidents;     it is found   that   not  all items of   trauma     (international      classification)     were    recorded.      This  study    concludes      that patients’    files in emergency      department      were   not  fully documented,       also   there   is no standardized     program   of  registration   of patient    files and   no  computerized     data   for this unit.