Assessment of quality of healthcare data management in antiretroviral records at Federal Medical Centre, Bida in North-central Nigeria

Abstract

Background/Objective: The quality of data especially in healthcare management is recognized as a relevant performance function to facilitate operating processes and to facilitate quality decision making. The study assessed documentation quality of antiretroviral (ART) patients’ records at the Federal Medical Centre, Bida Niger State, Nigeria. Methods/Design: A retrospective review of patients’ health record was conducted at the antiretroviral (ART) clinic, Federal Medical Centre (FMC) Bida for patients who are active in the clinic between 1st January 2017 and 31st December 2017. Out of 1,122 patients who attended the clinic, a total of 286 cases were systematically selected for the review. Result: Demographic information of patient was fairly documented in 248(86.7%) cases; almost all (98.9%) the folders had their personal care card(s) enclosed. Documentation of patient’s demographics on the care cards was also completed in 265 (92.7%) cases. Investigation form and prescriptions for the last six visits were well arranged in all cases 286(100%), documentation of vital signs was optimal in 270 (94.4%) cases while drug intake was well documented in 284 (99.3%) cases. There was serious lapse in clinical documentation of initial care assessment 236(82.5%) on the care card and also the completion of the same form 117(40.9%) among the clinicians; and adherence status of patient to care were also poorly documented 236(82.5%). The majority 251 (87.8%) of the records were not well tagged. Conclusion: Documentation of important clinical information is poor in the charts of patients attending ART clinic, FMC Bida and their folders were not properly fastened. Poor documentation in health records and proper safety of such might impede seamless continuity of care and might negatively affect the quality of care. The study recommends mandatory training and retraining of the staff involved and routine chart review in the adherence unit.