Authors :
Dr. Maureen Anikpe Okumoko; Dr. Ihekerenma Justina Binafeigha; Dr. Efetobore Perebodo Ogigbah; Dr. Gesitari Blessing Diriyai; Felix Olukayode Akinbami; Oliemen Peterside; Dr. Daniel Osasere Aiwansoba
Volume/Issue :
Volume 11 - 2026, Issue 6 - June
Google Scholar :
https://tinyurl.com/yc2jvt5j
Scribd :
https://tinyurl.com/fshwctn5
DOI :
https://doi.org/10.38124/ijisrt/26jun1544
Note : A published paper may take 4-5 working days from the publication date to appear in PlumX Metrics, Semantic Scholar, and ResearchGate.
Abstract :
Background:
Clinical documentation is an essential component of quality healthcare delivery. Accurate, complete and timely
documentation improves patient safety, enhances communication among healthcare providers and facilitates clinical
decision-making. Poor documentation, however, remains a persistent challenge in many healthcare institutions, particularly
in low- and middle-income countries.
Objective:
To assess the completeness and quality of clinical documentation and determine factors associated with documentation
practices among hospitalized patients.
Methods:
A cross-sectional study was conducted using 156 patient records. Data were extracted using a structured checklist
assessing patient demographics, documentation completeness, examination findings, frequency of patient review, and
discharge summaries. Documentation quality was categorized as poor, fair, or good. Statistical analysis included descriptive
statistics, chi-square test, Fisher's exact test, ANOVA, and logistic regression.
Keywords :
Clinical Documentation, Medical Records, Bayelsa, Documentation Completeness, Hospital Audit, Nigeria.
References :
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Background:
Clinical documentation is an essential component of quality healthcare delivery. Accurate, complete and timely
documentation improves patient safety, enhances communication among healthcare providers and facilitates clinical
decision-making. Poor documentation, however, remains a persistent challenge in many healthcare institutions, particularly
in low- and middle-income countries.
Objective:
To assess the completeness and quality of clinical documentation and determine factors associated with documentation
practices among hospitalized patients.
Methods:
A cross-sectional study was conducted using 156 patient records. Data were extracted using a structured checklist
assessing patient demographics, documentation completeness, examination findings, frequency of patient review, and
discharge summaries. Documentation quality was categorized as poor, fair, or good. Statistical analysis included descriptive
statistics, chi-square test, Fisher's exact test, ANOVA, and logistic regression.
Keywords :
Clinical Documentation, Medical Records, Bayelsa, Documentation Completeness, Hospital Audit, Nigeria.
