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Medical record system in Nigeria: observations from multicentre auditing of radiographic requests and patients├ó┬?┬? information documentation practices| Abstract

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Medical record system in Nigeria: observations from multicentre auditing of radiographic requests and patients├ó┬?┬? information documentation practices

Abstract

Adekunle Y Abdulkadir, Garba H Yunusa, Abdulkadir M Tabari, Ismail Anas, Julius A Ojo, Bidemi Akinlade, Bello M Suleman, Inyang Uyobong

Medical requests as made on simple structured forms worldwide could serve as a reliable Medical Records (MRs) to meet requirements for researches if properly documented and handled. This study sought to identify correctable deficiencies (omissions and inconsistencies) in medical requests filling and medical records handling. Settings and Design: Six Nigerian tertiary hospitals. Radiographic requests for the month of December, 2009 were examined for documentation of patients’ names, hospital number, age, sex, requesting doctor’s identities, consultant in charge, patient sources, Clinical information/history, diagnosis and date of request. Medical records handling and archiving were assessed by examining the unit record books of Radiology and other departments of the hospitals. These were compared for mutilations, missing pages and storage. Statistical analysis used: SPSS 15.0 for Windows. In all centres, there were variable non-documentation of patients’ age and sex, hospital number, doctors’ names and date of request. The names of patients and consultants in charge were commonly indicated. Unit record books generally suffered mutilations and in 27.2% - 33.2% of the requests, clinical information was inadequate or not provided. Radiological requests information provision and handling in our tertiary hospitals were inaadequate. Therefore, we encourage regular auditing, training and re-orientation of medical personnel for good record practices, and discourage the use of large volume record books to reduce paper damages and sheet loss from handling. Electronic back up of records is a must at every registration unit; else what is recorded today may neither be useful nor be available tomorrow.

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