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Sunday, August 31, 2014

Defending Patients' Rights through Proper Documentation


Except in teaching hospitals (which have even seen a significant decline in the practice of this time-tested pillar of medical service), proper documentation is seriously lacking in our hospitals, especially the private ones. It is not unusual to see only a diagnosis written down for the complaint(s) of the patient.  During post-mortem investigations, I have had opportunities to review the medical records of patients who were treated in some private or general hospitals prior to their demise. In some cases, the whole record of some patients who had been seen repeatedly in some health facilities would not be more than a full page. This has made understanding the circumstances of a death or some medical incidents difficult or impossible.

In many parts of Africa, it is possible to exploit the ignorance of patients and the undue paternalistic tendencies in the medical profession to deny patients the right to have complete and appropriate documentation of their medical conditions. The ability to benchmark the care a patient has received from a health facility or hospital has been seriously compromised, and medical records are essentially devoid of any records that could shed light on the amount and quality of care given to a patient. Sometimes, it appears this is a deliberate attempt by practitioners who appear to be in a hurry to move on to the next patient (or "case," as frequently used), which may be akin to processing patients like a factory mass production. However, every patient is unique and brings a distinct dimension to their medical condition, though some features may be similar to that of another patient but not identical. There is, therefore, no excuse for “over-summarized” and "common" documentation as adequate documentation. A contemporaneous account of a patient’s presentation is the standard expected of a medical practitioner or any health professional providing care to patients.

The responsibility, therefore, falls on health professionals to document every aspect of care given to patients, every history that influences the thought processes in arriving at a diagnosis, every finding in the physical examination that directs investigation, and every investigation that confirms diagnosis or excludes some clinical impressions. Proper documentation is good practice, protects patients from medical mistakes, and also makes the transfer of patients to another health facility or caregiver easier for the purpose of continuity of care. It is part of the medical obligation to give a good account of the confidence a patient reposes in a medical practitioner by presenting at a hospital and submitting themselves for the understanding of their peculiar medical conditions.

The rights of patients, especially in the developing world where there is limited supervision by relevant authorities of the quality of care given to patients by medical practitioners, require protection by all concerned. “If it is not documented, it is not done”, should be an applicable dictum in medical practice. Auditing systems in any health care delivery should include the quality of documentation, which should show the thoughts, plans, and steps that give rise to diagnosis, investigation, treatment, and follow-up, where applicable. Autopsy, being an audit process at the back end of healthcare, has often revealed inadequacies in documentation and how it negatively impacts patient outcomes. To prevent such unpleasant consequences, there is a need to place more emphasis on the importance of proper documentation in protecting patients' right to appropriate medical care.

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