Data quality assessment in healthcare: a 365-day chart review of inpatients' health records at a Nigerian tertiary hospital

Adeleke, Ibrahim Taiwo; Adekanye, Adedeji Olugbenga; Onawola, K. A.; Okuku, Alaba George; Adefemi, Samuel Adebowale; Erinle, Sunday Adesubomi; Shehu, AbdurRahman Alhaji; Yahaya, Olubunmi Edith; Adebisi, AbdulLateef Adisa; James, John Adeniran; AbdulGhaney, Oloundare Olanrewaju; Ogundiran, Lateef Mosebolatan; Jibril, Abdullahi Daniyan; Atakere, Moses Esimy; Achinbee, Moses; Abodunrin, Oluwaseun Ayoade; Hassan, Muhammad Wasagi

doi:10.1136/amiajnl-2012-000823

Cited by 36 publications

(49 citation statements)

References 11 publications

(12 reference statements)

Supporting

Mentioning

Contrasting

Order By: Relevance

“…On the other hand, it is evident from our study that clinical coding practices and especially, implementation of ICD-10 and its procedure counterpart, ICD-10-PCS is no longer a mirage in Nigeria as 88% of healthcare settings in Nigeria practice full diagnoses coding with ICD-10 and 39% carry out procedure coding using ICD-10-PCS. This further supports a study [11] from Nigeria that most (81%) of the discharged patients' folders reviewed in the study were coded. The preponderance of paper-based health records systems [31][32] has multiplying effects on the practice of clinical coding seeing that as low as 7% operate automated coding.…”

Section: Discussionsupporting

confidence: 72%

“…Cunningham et al [43] also reported insufficient information for specific code assignment. Similarly, documentation issues have been of primary concern for coding quality [44] and it has been suboptimal in developing nations such as Nigeria [11] where discharge summary is reported to be grossly underutilized. Bad clinical documentation makes information inaccessible [45] and causes coding errors [46].…”

Section: Discussionmentioning

confidence: 99%

“…Though it was reported [11][12][13] not to be written always or vital part omitted when written, it provides the information to support clinical documentation review process and clinical coding. While it is true that clinical coders' variability in coding may be related to the inadequacy of their training and experience, physician's documentation can impede accurate interpretation of medical charts by the coders [14].…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Current Clinical Coding Practices and Implementation of ICD-10 in Africa: A Survey of Nigerian Hospitals

Adeleke¹,

Ajayi²,

Jimoh³

et al. 2015

AJHR

View full text Add to dashboard Cite

Section: Discussionsupporting

confidence: 72%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Current Clinical Coding Practices and Implementation of ICD-10 in Africa: A Survey of Nigerian Hospitals

Adeleke¹,

Ajayi²,

Jimoh³

et al. 2015

AJHR

View full text Add to dashboard Cite

“…In spite of this, the global relevance and importance of computer and the Internet for communication, information retrieval and support for healthcare service delivery, training and research cannot be overstated. In the same vein, accurate, promptly documented and regularly reviewed healthcare information is essential to healthcare delivery system [17]. This may not be possibly achieved without the use of computer and the Internet in processing healthcare information especially, in this hi-tech age [16].…”

Section: Introductionmentioning

confidence: 99%

Computer and Internet Use among Tertiary Healthcare Providers and Trainees in a Nigerian Public Hospital

Adeleke¹

2015

AJHR

Self Cite

View full text Add to dashboard Cite

Abstract:The Nigerian healthcare system is characterized with paper-based health information management systems and grossly inadequate IT-skilled healthcare providers. Nonetheless, the emerging digitization and globalization has the potentials to speed up the transformation of the current healthcare systems and revolutionize the provider-consumer relationship between healthcare providers and their teeming patients. This cross-sectional study determined the utilization of computer and the Internet among healthcare providers and trainees in a Nigerian public hospital (n=232). More than half (112, 52 %) of the participants were females and the vast majority (154, 72.3 %) were aged forty years or below with a Mean age of 35 ± 9 years. More than a third (78, 36.6 %) of the participants had used the Internet for over three years and early exposure to computer use did significantly influence (χ2= 3.19; p= 0.00) their current computer use. Updates on professional issues appeared the major reason (98, 46.0 %) for searching the Internet and this was mostly accessed (149, 70.0 %) through cell phone. Google Scholar was the most (154, 72.3 %) deployed search engine and participants were often constrained (93, 43.7 %) to use these technologies by inadequate time due to their busy schedules. For better appreciation of the technologies, participants solicited for further training in health IT. Healthcare providers and trainees at Federal Medical Centre, Bida have good disposition towards computer and Internet use especially to enhance their professional practice and to improve patient care quality. They overwhelmingly indicated interests for further ICT training in order to boost their sources of information for an improved healthcare practice. Any effort made to enrich their sources of information and to enhance their usability of these technologies would be worthwhile.

show abstract

“…Although the results have generally shown that most of the items checked on nursing records in the UTI-P are adequate in relation to safety aspects, it is believed that improvements can still be made through continuing education programs made available to nursing professionals (14,15) . It has been noted that in health care…”

Section: Discussionmentioning

confidence: 99%

Registros de enfermagem em unidades de terapia intensiva pediátrica: estudo descritivo

et al. 2017

View full text Add to dashboard Cite

Continuity of care depends on the sharing of information between professionals, which occurs mainly through completion of patient records. Failure to transmit or receive messages may result in risks to patient safety and reflect on the quality of care provided. Aim: To verify whether the nursing records in the medical records of patients hospitalized in Unidades de Terapia Intensiva Pediátrica (UTI-P -Units of Pediatric Intensive Care) correspond to the safety needs recommended in the literature. Method: This is a descriptive and quantitative study, through documentary research in the nursing records of 92 medical records, in three UTI-P.Results: It was found that in 21.8% of the records there were erasures and in 26.1% there was no complete identification of the care professional. Discussion: Records should not present erasures, as they make it difficult to plan care. In addition, professionals must include their name and registration number at the end of the information noted. Conclusion: Records were adequate according to the safety recommendations, although some aspects are still lacking in relation to nursing standards.

show abstract

Data quality assessment in healthcare: a 365-day chart review of inpatients' health records at a Nigerian tertiary hospital

Cited by 36 publications

References 11 publications

Current Clinical Coding Practices and Implementation of ICD-10 in Africa: A Survey of Nigerian Hospitals

Current Clinical Coding Practices and Implementation of ICD-10 in Africa: A Survey of Nigerian Hospitals

Computer and Internet Use among Tertiary Healthcare Providers and Trainees in a Nigerian Public Hospital

Registros de enfermagem em unidades de terapia intensiva pediátrica: estudo descritivo

Contact Info

Product

Resources

About