TITLE:
Health Workers’ Documentation Process as a Prerequisite to the Integration of Patient Care at a Regional Referral Hospital in Uganda
AUTHORS:
Mary Grace Nakate, Mary Moleki, Ahmed Sarki, Valerie Fleming
KEYWORDS:
Documentation, Clinical Records, Integrated Patient Care, Audit Records, Uganda
JOURNAL NAME:
Open Journal of Nursing,
Vol.12 No.9,
September
23,
2022
ABSTRACT: Background: Integrated patient care is necessary for better care outcomes. Documentation enhances the integration of care; however, in the Ugandan setting, documentation of care is poor (e.g., omissions and incomplete records) and integration of patient care is not visible. This study presents a review of patient health records that was undertaken to understand documentation of care at a regional referral hospital in Eastern Uganda. This information will help in developing a documentation model to facilitate the integration of patient care in Uganda. Methodology: This retrospective review involved 513 patient health records from the medical-surgical, pediatric, and obstetric/gynecological departments of Jinja Regional Referral Hospital. Data were collected using checklists. Stratified sampling was used to capture variations in ward unit records and identify a fair representation of each department. Data were analyzed with descriptive and inferential statistics. All analyses were performed with SPSS version 22. Results: On average, the study hospital attended to 1000 patients per day and discharged 100 patients per ward unit per month. Our record review showed that documentation by both nurses and doctors was incomplete, and care was fragmented. However, doctors documented care more often than nurses, although the integration of patient care was not evident in doctors’ documentation. Conclusion: To establish integrated patient care, documentation must meet standards set by relevant professional bodies. The findings of this study will inform the development of a feasible documentation model to facilitate the integration of patient care in Uganda.