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

Abstract

Introduction

Health records document the pertinent facts of a patient's life and health history, including past and present illness(es) and treatment(s), written down by the health professionals handling the patient's care. The records must be compiled in a timely manner and contain sufficient data to identify the patient, support the diagnosis or reasons for the healthcare encounter, justify the treatment, and accurately document the results.¹ They are the visible evidence of the hospital's clinical activities and accomplishments. Since they are the basis of any health institution, documentation of every contact of each patient with a healthcare provider must be comprehensive and robust to the scrutiny of auditors or attorneys.²

It is often said that an adequate health record indicates adequate care, and conversely, a poor health record indicates poor care. Indeed, a patient who received poor care can have a complete and thorough record, but the reverse is more likely to be true, that is, a patient may have received adequate care which is poorly documented.¹ The quality of health records depends on the health information recorded by the healthcare professionals authorized to provide and document such care. The term ‘data quality’ refers to the characteristics and attributes of the data, specifically: accuracy, accessibility, comprehensiveness, consistency, currency, definition, granularity (detail contained), precision, relevancy, and timeliness.³ Problems with data quality make the health record linkage process cumbersome, unreliable, and of little value to organizations, providers, and patients.⁴

The information contained in the record is essential, but the process of documenting it is often considered a lesser priority by many health caregivers. A busy physician may inadvertently record a progress note in the wrong patient's health records. A nurse may get a call to assist a patient and forget to record medication given to another patient.¹ The value of health records is ultimately dependent on their completeness and accuracy in providing patient information. This may vary with physician–patient communication, the patient's condition and the physician's documentation style. Variability in coding diagnoses and procedures may be related to the coder's training and experience. In addition, inadequate physician documentation may also affect accurate interpretation of medical charts by coders and consequently the validity of administrative data.⁵ Clinical documentation in computer-based records has been found to be more complete and more appropriate for clinical decisions than that in paper-based records.⁶ In Nigeria, health record production is still based on dictation and paper-based systems as electronic health records and modern health information systems have not been widely adopted or where adopted (unpublished data), have not been thoroughly implemented. When dictation or a manual system is used, the production of accurate health records depends on the providers' record keeping practices.⁷

Good quality healthcare data play a vital role in the planning, development, and maintenance of healthcare services. Quality health records are essential for the maintenance of optimal healthcare.⁸ Health record review is important for quality assessment and clinical epidemiology research as researchers can access data on previous events.⁹ Improving the quality of healthcare data in patient health records can affect clinical and administrative decision making in many ways¹⁰ and impact on health economics, increase patient safety, provide evidence to support clinical decision making through healthcare research, and improve the information provided to patients on their illness and care, and the effectiveness of clinical care pathways.

Patient health record review has improved the chart documentation of care by medical house officers¹¹ and has impacted on the quality of health record documentation.¹² It has enhanced communication among healthcare teams resulting in improved patient care.¹³ Health record review offers an attractive mechanism for evaluating clinical competence because of its ease of implementation relative to other methods.¹¹

Ensuring quality patient care information is challenging in light of complex and ever changing healthcare delivery systems.¹ Responsibility devolves to all healthcare providers as many healthcare administrators recognize that quality improvement can enhance services offered,⁸ with leadership roles taken by healthcare administrators, senior doctors, and senior staff in all departments. These personnel need to ensure that their staff maintain quality healthcare documentation at all times. Most importantly, senior members of health information departments must ensure adequate documentation collection, analysis, and assessment in order to guarantee the completeness, availability, and accessibility of health records.⁸ Therefore, healthcare institutions must facilitate regular analysis of health records so that good patient care information systems are maintained.

Inadequacies in clinical documentation have been reported at the Federal Medical Centre, Bida by the Department of Health. This study sought to verify such information more scientifically by assessing the quantitative properties of inpatient health records at the hospital.

Methods

Results

Discussion

The abstracted records reflect the discharge patterns at the Federal Medical Centre, Bida in 2008. All specialties and subspecialties in the hospital were covered in contrast to the study by O'Neil et al ¹⁸ where only one department was examined. In our study, records of maternal healthcare constituted almost half (336, 45.80%) of the total records examined.

Generally, our results demonstrate consistency and promptness in documenting care. This is in accordance with the findings by Durkin² but contrary to those of Gunningberg et al ¹⁹ where the quality of documentation in patients' health records was poor overall. However, our study revealed that laboratory investigation orders were not consistently signed when ordered, the patient's unit number was often not correctly recorded, and discharge summaries were largely not utilized. Failure to sign forms ordering investigations might reflect a reluctance to take full responsibility for care, while the only fair entry of unit numbers would result in the loss of records of individual patients. The unit number is the unique identifier that distinguishes one patient from another especially in the study setting (Bida) where more than one member of a family may share the same name. Non-completion of the discharge summary is contrary to clinical documentation standards as identified by Kind and Smith.²⁰ Incorrect entry of unit numbers and non-completion of discharge summaries resulting in incomplete medical charts produces suboptimal administrative data for management decision making.⁵ Nevertheless, when discharge summaries were written, they were correctly documented, suggesting that hospital healthcare providers possess the required skills but lack the will to properly complete the forms.

We found that surgical records were more promptly documented and there was better utilization of surgical discharge summaries than in other specialties. A higher proportion of discharge summaries were correctly completed in medically related records and laboratory investigations were ordered more frequently for maternal cases. However, documentation of pediatric cases was only average, while discharge summaries were not completed at all in psychiatry. In addition, the case notes in patients' health records were not always chronologically arranged and tagged, perhaps due to the fact that file tags were frequently out of stock during the period under review. It is unacceptable that some of the discharged patients' health records were not properly reviewed or coded, as standard practice in disease classification and clinical coding as recommended by WHO²¹ is that the records of every discharged patient should be clinically coded, which is important for determining reimbursement for healthcare facilities²² and improves clinical research.

Overall, our findings demonstrate that adherence to documentation standards was suboptimal, especially as regards the entry of unit numbers on progress notes and the non-completion of discharge summaries in most cases. Given the fundamental role of the discharge summary in healthcare transitions, its non-completion is of concern and may impact patient safety.²⁰

Our findings suggest that a periodic hospital-wide comprehensive review of patients' health records in a clinical documentation improvement program²³ would reveal other errors in documentation standards as specified by Kind and Smith.²⁰ Such a review would improve patient care,^{12 24} lead to higher reimbursement,²² and help evaluate the competence of clinicians, clinical support professionals, and other hospital staff.⁶

Conclusion and recommendations

There were noticeable inadequacies in clinical documentation, especially gross underutilization of the discharge summary. The implementation of a statutory clinical documentation improvement program is necessary to improve data quality in the hospital. Likewise, routine chart review in the admission and discharge unit and the clinical coding and indexing unit of the hospital needs to be strengthened.

In addition, all contributors to patients' medical charts require training in health data quality through the existing hospital continuing education programs and mentoring by senior colleagues.

Major limitations in our study are the lack of specific published work on this topic and the small sample size. More robust data quality improvement studies would be useful in the future.

Acknowledgments

Footnotes

References