Impact of Effective Documentation of Patient Health Information/Data in the Management of Patient in Health Care Delivery System (PDF)

Filed in Articles by on July 31, 2022

Impact of Effective Documentation of Patient Health Information/Data in the Management of Patient in Health Care Delivery System.


The study examined “The impact of effective documentation of patient Health Information/Data in the management of patient in Health care delivery system”.

The specific objectives are (i) To investigate the factors militating against effective documentation practice in University of Uyo Teaching Hospital Uyo. (ii) To assess the importance of effective documentation in health care delivery system (iii) To find out ways of improving proper patient.

The study area was the four departments in the University of Uyo Teaching Hospital.

To deal exhaustively with the objectives of the study and problem raised in the study, some related literatures were reviewed.

A simple Random Sampling method was accepted and one hundred and twenty (120) respondents were selected using questionnaire as a major tool for data collection and simple percentage for data analysis.

The population was staff from the four department selected. The findings of the study revealed that 100% of the respondent accepted that effective documentation of patient health record helps to provide communication with both Doctors and Patients.

It also provides accurate and best possible information records in each patient case folder. It also reveals that lack of space, lack of electronics health record, etc are the factors militating against effective health record.

The researcher recommends that adequate facilities and space should be provided for health record department for smooth running of the department.


Certification  –            i

Dedication     –             ii

Acknowledgement   –        iii

Abstract                iv

Table of content       –      v

List of tables –                 viii


1.1       Background of the study    –    1

1.2       Statement of the problem   –          3

1.3       Objective of the study          –        3

1.4       Research questions       –           4

1.5       Significance of the study   –          4

1.6       Scope of the study   –           –  4

1.7       Limitation of the study         5

1.8       Operational definition of terms          5


2.1       Introduction   –           –           6

2.2       Overview of document        –    6

2.3       The ethical standard, obligation and legal implicationnof documentation in health care system –    7

2.4       Basic principle and purpose of documentation                8

2.5       Records management           9

2.6       Impact of effective documentation of patient health information        –           10

2.7       Values of documentation of patient healthcare information   –           –           11

2.8       Privacy, confidentiality, and patient right to health information documentation       12

2.9       Documentation guidelines/records –     13

2.10    Factors militating against proper documentation of patient health care information    14


3.0       Introduction   –           16

3.1       Research design     –  16

3.2       Population of the study             16

3.3       Sample size and sampling technique        16

3.4       Research instrument          –      17

3.5       Validity of instruments             17

3.6       Method of data collection procedure          17

3.7       Methods of data analysis   –        17


4.1       Introduction   –              18

4.2       Demographic information of respondent              18

4.3       Analysis of finding      21


5.1       Introduction       27

5.2       Summary          27

5.3       Conclusion   –          28

5.4       Recommendations  –        28

5.5       References



Health record is a multifunctional document that is used to communicate and document critical information about patient’s medical care among health care professionals.

Comprehensive medical records are a cornerstone in the quality and efficiency of patient care during the hospitalization and in subsequent follow-up visits as they can provide a complete and accurate chronology of treatments.

Patient results and future plans for care (Benjamin et al., 1980). Despite the importance of medical records to high quality and efficient care, management of medical records, particularly in developing countries, has not been a priority.

Whereas in many high-income countries the medical records function is supported by extensive use of information technology, medical record in developing countries are generally inadequately supported and poorly managed.

Although there are some exceptions with new open-source medical records systems becoming available, those are yet not widely used.

In this study, we report on a re-engineering process to improve medical records management in a rural hospital (Osundina 2005).

Medical records management systems can improve completeness and availability of medical information, medical record documentation forms the basis for proper epidemiologic evaluation of various patterns of disease as well as more accurate monitoring of quality care delivered in the hospital.

Ideally, patient information documented comprehensive medical records at the facility level can contribute to a national system for epidemiologic surveillance and reporting, which can help with future health system planning and evaluation (Patrick et al., 2010).

The patient record is the principal repository for information concerning a patient’s health care. It affects in some way, virtually everyone associated with providing, receiving, or reimbursing healthcare services.

Despite many technological advances in healthcare over the past few decades, the typical patient record of today is remarkably similar to the patient record of 50 years ago.

This failure of patient records to evolve is now creating additional stress within the already burdened U.S. healthcare system as the information needs of practitioners, patients, administrators, third-party prayers, researchers and policy makers often go unmet (Arema 1999).


Aremu, H. B., (1999). Health Record Management 1&2 (2nd edition) Decency Ltd.
Benjamin, Bernard, (1980). Medical Record (2nd edition) London William Heinemana
Besser, (1999). Paperless documentation
Bulter, Timothy W. G. Keongleong &Linda N. Everett, (1996). The operations management Role in Hospital Strategic planning, journal of operations management 14(137-156)
Daller, (2002). Effective documentation. Impact of space and equipment
Dr. Vawdrey, (2012). Effective documentation
Light Castle Technical consulting (2013).
Osundina S., (2005). Principles and practice of Health Record management.
Singh, Vikas (2006). Use of queuing models in Healthcare, Department of Health policy and management, University of Arkansas for Medical Sciences.
Torres J. E. and Guo, K. L., (2004). Quality improvement teahniques to improve patient satisfaction. International journal of Health care Quality Assurance, 17(b), 334-338.
White, Denisk L. Craig M. Froehle, Kenneth J. Klassen, (2011). The effect of integrated scheduling and capacity policies on clinical efficiency. Production and operation management, Vol 20(3), PP 442-455.

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