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Poor Documentation and Absence of Discharged Summaries: Causes, Implications and Mitigation.

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Documentation in clinical services is the record of health care that is scheduled and provided to separate patients/clients by health care professionals. Quality documentation is a life wire of effective and efficient health care delivery system in health care institutions, it could either be paper or electronic based, structured of unstructured. Poor documentation can be easily defined as any instance of reporting that fails to accurately tell the patient's story, and which, by consequence, fails to result in accurate billing and claims filing. Discharge summary may be described as a clinical report prepared by a physician or other health professional at the conclusion of a hospital stay or series of treatments. Absence of discharge summary can be categorised as poor documentation. The main objective of the study is to identify causes, implications and mitigations of poor documentation and absence of discharge summaries in patient care. The study was a desk top study which employed qualitative review of literatures with theoretical discussion from professional point of view.

The study identified some reasons while discharge summary may not be available after the patient has been discharged from the hospital, the implications and mitigation of poor documentation with focus on absence of discharged summary. The study concludes that poor documentation and absence of discharge summaries remain challenge in patient care management with negative implications on patient health, hence, the need to educate healthcare practitioners and enforce policies that will enhance its being written as required.

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