Availability legibility and adequacy of diagnosis as entered in bed head ticket in a base hospital Sri Lanka: a descriptive cross-sectional study
Autor(a) principal: | |
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Data de Publicação: | 2022 |
Outros Autores: | |
Tipo de documento: | Artigo |
Idioma: | eng |
Título da fonte: | MedNEXT Journal of Medical and Health Sciences |
Texto Completo: | https://mednext.zotarellifilhoscientificworks.com/index.php/mednext/article/view/160 |
Resumo: | Introduction: Hospital information storage is done through an internationally accepted coding system. It is very important to have an accurate diagnosis for proper coding. Ministry of Health has issued a circular (No-01-05/99) for the documentation of Bed Head Ticket (BHT) including writing the correct diagnosis. Objective: To assess the availability, legibility, and adequacy of diagnosis as entered in the BHTs of selected wards in a base hospital in Sri Lanka. Methods: Descriptive cross-sectional study was conducted to assess availability, legibility, and adequacy of diagnosis as entered in 384 BHTs of selected wards in a Base Hospital in Sri Lanka. A data Extraction sheet (DES) was used as a study instrument. Results: Out of 384 BHTs diagnosis were not available in 12 (3.13%) BHTs and diagnosis were illegible in 36(6.99%) BHTs. In 244(67.59%) BHTs diagnosis were written as abbreviations. Only in136(37.46%) BHTs, diagnosis were written in block capital letters. Conclusion and recommendation: Documentation diagnosis in the BHTs is not according to the standards. Therefore, medical administrators, policymakers, and clinicians should take urgent actions to improve documentation diagnosis in BHTs. |
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Availability legibility and adequacy of diagnosis as entered in bed head ticket in a base hospital Sri Lanka: a descriptive cross-sectional studyBed Head TicketAvailabilityLegibilityAdequacyDiagnosisCodingIntroduction: Hospital information storage is done through an internationally accepted coding system. It is very important to have an accurate diagnosis for proper coding. Ministry of Health has issued a circular (No-01-05/99) for the documentation of Bed Head Ticket (BHT) including writing the correct diagnosis. Objective: To assess the availability, legibility, and adequacy of diagnosis as entered in the BHTs of selected wards in a base hospital in Sri Lanka. Methods: Descriptive cross-sectional study was conducted to assess availability, legibility, and adequacy of diagnosis as entered in 384 BHTs of selected wards in a Base Hospital in Sri Lanka. A data Extraction sheet (DES) was used as a study instrument. Results: Out of 384 BHTs diagnosis were not available in 12 (3.13%) BHTs and diagnosis were illegible in 36(6.99%) BHTs. In 244(67.59%) BHTs diagnosis were written as abbreviations. Only in136(37.46%) BHTs, diagnosis were written in block capital letters. Conclusion and recommendation: Documentation diagnosis in the BHTs is not according to the standards. Therefore, medical administrators, policymakers, and clinicians should take urgent actions to improve documentation diagnosis in BHTs.Faceres2022-04-25info:eu-repo/semantics/articleinfo:eu-repo/semantics/publishedVersionArticleapplication/pdfhttps://mednext.zotarellifilhoscientificworks.com/index.php/mednext/article/view/16010.54448/mdnt22205MedNEXT Journal of Medical and Health Sciences; Vol. 3 No. 2 (2022): MedNEXT - May 2022MedNEXT Journal of Medical and Health Sciences; v. 3 n. 2 (2022): MedNEXT - May 20222763-567810.54448/mdnt222reponame:MedNEXT Journal of Medical and Health Sciencesinstname:Faculdade de Medicina em São José do Rio Preto (Faceres)instacron:FACERESenghttps://mednext.zotarellifilhoscientificworks.com/index.php/mednext/article/view/160/151Copyright (c) 2022 MedNEXT Journal of Medical and Health Scienceshttps://creativecommons.org/licenses/by/4.0info:eu-repo/semantics/openAccessWanninayake, IndikaPerera, H. S. R.2022-04-20T12:33:14Zoai:ojs2.mednext.zotarellifilhoscientificworks.com:article/160Revistahttps://mednext.zotarellifilhoscientificworks.com/index.php/mednextPUBhttps://mednext.zotarellifilhoscientificworks.com/index.php/mednext/oaimednextjmhs@zotarellifilhoscientificworks.com2763-56782763-5678opendoar:2022-04-20T12:33:14MedNEXT Journal of Medical and Health Sciences - Faculdade de Medicina em São José do Rio Preto (Faceres)false |
dc.title.none.fl_str_mv |
Availability legibility and adequacy of diagnosis as entered in bed head ticket in a base hospital Sri Lanka: a descriptive cross-sectional study |
title |
Availability legibility and adequacy of diagnosis as entered in bed head ticket in a base hospital Sri Lanka: a descriptive cross-sectional study |
spellingShingle |
Availability legibility and adequacy of diagnosis as entered in bed head ticket in a base hospital Sri Lanka: a descriptive cross-sectional study Wanninayake, Indika Bed Head Ticket Availability Legibility Adequacy Diagnosis Coding |
title_short |
Availability legibility and adequacy of diagnosis as entered in bed head ticket in a base hospital Sri Lanka: a descriptive cross-sectional study |
title_full |
Availability legibility and adequacy of diagnosis as entered in bed head ticket in a base hospital Sri Lanka: a descriptive cross-sectional study |
title_fullStr |
Availability legibility and adequacy of diagnosis as entered in bed head ticket in a base hospital Sri Lanka: a descriptive cross-sectional study |
title_full_unstemmed |
Availability legibility and adequacy of diagnosis as entered in bed head ticket in a base hospital Sri Lanka: a descriptive cross-sectional study |
title_sort |
Availability legibility and adequacy of diagnosis as entered in bed head ticket in a base hospital Sri Lanka: a descriptive cross-sectional study |
author |
Wanninayake, Indika |
author_facet |
Wanninayake, Indika Perera, H. S. R. |
author_role |
author |
author2 |
Perera, H. S. R. |
author2_role |
author |
dc.contributor.author.fl_str_mv |
Wanninayake, Indika Perera, H. S. R. |
dc.subject.por.fl_str_mv |
Bed Head Ticket Availability Legibility Adequacy Diagnosis Coding |
topic |
Bed Head Ticket Availability Legibility Adequacy Diagnosis Coding |
description |
Introduction: Hospital information storage is done through an internationally accepted coding system. It is very important to have an accurate diagnosis for proper coding. Ministry of Health has issued a circular (No-01-05/99) for the documentation of Bed Head Ticket (BHT) including writing the correct diagnosis. Objective: To assess the availability, legibility, and adequacy of diagnosis as entered in the BHTs of selected wards in a base hospital in Sri Lanka. Methods: Descriptive cross-sectional study was conducted to assess availability, legibility, and adequacy of diagnosis as entered in 384 BHTs of selected wards in a Base Hospital in Sri Lanka. A data Extraction sheet (DES) was used as a study instrument. Results: Out of 384 BHTs diagnosis were not available in 12 (3.13%) BHTs and diagnosis were illegible in 36(6.99%) BHTs. In 244(67.59%) BHTs diagnosis were written as abbreviations. Only in136(37.46%) BHTs, diagnosis were written in block capital letters. Conclusion and recommendation: Documentation diagnosis in the BHTs is not according to the standards. Therefore, medical administrators, policymakers, and clinicians should take urgent actions to improve documentation diagnosis in BHTs. |
publishDate |
2022 |
dc.date.none.fl_str_mv |
2022-04-25 |
dc.type.driver.fl_str_mv |
info:eu-repo/semantics/article info:eu-repo/semantics/publishedVersion Article |
format |
article |
status_str |
publishedVersion |
dc.identifier.uri.fl_str_mv |
https://mednext.zotarellifilhoscientificworks.com/index.php/mednext/article/view/160 10.54448/mdnt22205 |
url |
https://mednext.zotarellifilhoscientificworks.com/index.php/mednext/article/view/160 |
identifier_str_mv |
10.54448/mdnt22205 |
dc.language.iso.fl_str_mv |
eng |
language |
eng |
dc.relation.none.fl_str_mv |
https://mednext.zotarellifilhoscientificworks.com/index.php/mednext/article/view/160/151 |
dc.rights.driver.fl_str_mv |
Copyright (c) 2022 MedNEXT Journal of Medical and Health Sciences https://creativecommons.org/licenses/by/4.0 info:eu-repo/semantics/openAccess |
rights_invalid_str_mv |
Copyright (c) 2022 MedNEXT Journal of Medical and Health Sciences https://creativecommons.org/licenses/by/4.0 |
eu_rights_str_mv |
openAccess |
dc.format.none.fl_str_mv |
application/pdf |
dc.publisher.none.fl_str_mv |
Faceres |
publisher.none.fl_str_mv |
Faceres |
dc.source.none.fl_str_mv |
MedNEXT Journal of Medical and Health Sciences; Vol. 3 No. 2 (2022): MedNEXT - May 2022 MedNEXT Journal of Medical and Health Sciences; v. 3 n. 2 (2022): MedNEXT - May 2022 2763-5678 10.54448/mdnt222 reponame:MedNEXT Journal of Medical and Health Sciences instname:Faculdade de Medicina em São José do Rio Preto (Faceres) instacron:FACERES |
instname_str |
Faculdade de Medicina em São José do Rio Preto (Faceres) |
instacron_str |
FACERES |
institution |
FACERES |
reponame_str |
MedNEXT Journal of Medical and Health Sciences |
collection |
MedNEXT Journal of Medical and Health Sciences |
repository.name.fl_str_mv |
MedNEXT Journal of Medical and Health Sciences - Faculdade de Medicina em São José do Rio Preto (Faceres) |
repository.mail.fl_str_mv |
mednextjmhs@zotarellifilhoscientificworks.com |
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