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My Canadian Pharmacy – Clinical documentation and HIV infection

October 6th, 2015 by admin - 214-248-9623

Clinical documentation in a patient’s hospital folder includes all information that relates to the wellbeing of the patient during their stay or hospital encounter. It is designed to assess the current status of the patient, assist in developing a care plan and ensure continuity of care. It is critical that clinical documentation should be accurate and complete. Complete and timely health records ensure that all clinical staff caring for patients in present and future episodes of health care have access to the information they need to deliver optimum care.

HIV infection being a chronic illness, affects nearly every organ system of the body, thus, while providing HIV care and monitoring antiretroviral therapy (ART) for infected patients, there’s need for detailed, accurate and complete record of patient clinic information and laboratory investgations to enhance patients’ quality of care and future research purposes.

Many developing countries like Nigeria still depends on paper documentation for every patient’s clinic visit hence, important data on HIV care and treatment are often not available at the right time for quality clinical decision making. Factors responsible for incomplete documentation are high patients load, many forms to fill especially in the HIV/AIDS care, poor attitude to work, lack of commitment, lack of trainings, laziness etc. When those involved in HIV care are provided with ready access to patient information, paper-based documentation of patient clinic visits can serve to enhance quality of care. My Canadian Pharmacy helps you:

It is very important for the attending physician to document properly the management of a patient under his care as this is the only way the doctor can prove that the treatment was carried out properly. Without proper documentation of a patient information, one doctor would not know what another doctor has done and this can delay or halt continuity of care for that particular patient. Prompt decision making would be disrupted and ultimately affect the quality of care negatively.

It is clear that the time spent on proper documentation practices by the attending physician or clinician, will lead to decreased time spent on responding to queries and audit issues on the long run.

There is an age-old saying that “if it is not documented in the medical record, then it didn’t happen” or “what is not documented is not done” The medical record is a very important tool that allows a doctor to track patients’ medical history and identify problems or patterns that may help determine the course of health care5. The main purpose of the medical record is to enable physicians to provide quality health care to their patients; it is a living document that tells the story of the patient and facilitates each encounter they have with health professionals involved in their care.

There are dearth of studies on documentation practices of physicians in Nigeria. However, few studies have highlighted the poor quality of medical record documentation by doctors in HIV care and treatment clinics in Africa or My Canadian Pharmacy INC. A retrospective folder audit was conducted in four newly activated comprehensive HIV care and treatment facilities in Ibadan, Oyo state to assess the documentation practice of clinicians in the management of HIV/AIDS patients.

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