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: Wanninayake, Indika
• Data de Publicação: 2022
• Outros Autores: Perera, H. S. R.
• 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
• topic: Bed Head Ticket; Availability; Legibility; Adequacy; Diagnosis; Coding

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.