Document Type : Original Article
Authors
1
Department of Forensic Medicine and Toxicology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
2
forensic medicine and clinical toxicology department, faculty of medicine, Ain shams university, Cairo, Egypt.
3
Forensic medicine and toxicology Faculty of medicine Ain Shams University Cairo Egypt
Abstract
Background: Medical documentation is the primary source of health information. Documentation is as important as the quality of patient care given. Healthcare professionals are accountable for their actions and their omissions in record keeping. Aim of the work: To assess the current status of the medical documentation process in the Poison Control Center Ain Shams University Hospitals (PCC ASUH), and its extent of completeness and quality to reduce liability for litigations. Methods: This retrospective study was conducted on 150 Files from the archive of PCC ASUH, 50 files from each studied group (ER, inpatient, ICU). Files belong to patients who visited the PCC for medical help from January 2022 to December 2022. Assessment and evaluation of each file according to a designated checklist, which included presence of facility policy supporting proper medical documentation, and the fulfillment of the necessary documentation components. The acquired data were scaled according to degree of fulfillment, tabulated, and statistically analyzed. Results: The current study revealed that no written, declared, accessible clinical documentation policy was found. The comparison showed some items, such as patient personal data, emergency contact, main complaint, fluid chart, and discharge instructions were significantly different between studied groups. Other items were not statistically different, as either because they were equally absent in all groups, such as allergies, critical incidents form and follow up appointment after discharge; or because they were fulfilled in all groups, such as admission date, time, and reason. Conclusion: The current study revealed that the documentation process in the inspected patients’ files during the period from January 2022 to December 2022, were not up to the documentation standards.
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