Clinical Documentation Practice: A Study of Doctors’ Medical Documentary Compliance in Government Hospitals in Gampaha District, Sri Lanka

Abstract

Doctors play a key role in health information system through clinical documentation. The study aimed to assess doctors’ compliance with national medical documentation standards. The study was carried out in government hospitals having in-ward patient care facilities in Gampaha district, Sri Lanka. The doctors’ knowledge and practices were assessed using a questionnaire. 500 Bed Head Tickets (BHTs) which are the medical records of inward patients, were audited in selected government hospitals in the same district using a check list to ascertain the doctors' compliance with standards in practice. Only 29.46% doctors were aware of the government circular on standards of medical record. Although 82.84%, 66.37% and 76.3% doctors knew that final diagnosis should be written according to International Classification of Diseases (ICD) 10, in block capitals and without any abbreviations, respectively. Only 7.61% BHTs were found to have fulfilled all standards. There were gaps in the knowledge of doctors regarding standards in clinical documentation practice. The awareness of and reference to published guidelines were not satisfactory. Poor transfer of knowledge into practice was evident by the results of BHT survey. As publishing guidelines or teaching alone may not improve the compliance of doctors with the standards in clinical documentation practice, more innovative strategies should be sought for.

Keywords:

• Clinical documentation
• standards
• doctors
• knowledge
• practices

Acknowledgment

The authors acknowledge the support extended from medical record officers of all institutions included in the study.

Data Availability Statement

The data can be made available to a third party when requested from the author.

Disclosure Statement

The author has no conflict of interest regarding the study.

Funding

The research was fully self-funded by author.