Accuracy of Documented History among Doctors Referring Patients to a Paediatric Neurology Clinic in Rivers State, Nigeria
Published: 2021-12-22
Page: 184-190
Issue: 2021 - Volume 4 [Issue 1]
Woroma Wonodi *
Department of Paediatrics, Rivers State University Teaching Hospital, Port Harcourt, Nigeria and Department of Paediatrics and Child Health, College of Medical Sciences, Rivers State University, Nkpolu-Oroworukwo, Nigeria.
Tamunoiyowuna Grace Okari
Department of Paediatrics, Rivers State University Teaching Hospital, Port Harcourt, Nigeria and Department of Paediatrics and Child Health, College of Medical Sciences, Rivers State University, Nkpolu-Oroworukwo, Nigeria.
*Author to whom correspondence should be addressed.
Abstract
Background: History taking is a means of communication between patients and doctors. Documentation of such history is an effective means of communication between all concerned in patient management.
Objectives: To assess the accuracy of documentation of history obtained by doctors referring patients to a Paediatric neurology clinic in Rivers State.
Methodology: A retrospective study of 145 patients referred to a Paediatric neurology clinic by doctors over a 4 year period - July 2017 to July 2021. The case notes were assessed for accuracy of documented clinical history obtained. Data was extracted, coded and analysed using the Statistical Package for Social sciences (SPSS) IBM version 25.0 (Armonk, NY).
Results: A total of 145 children aged 2 months to 16 years were referred by doctors to the Paediatric neurology Clinic. Most of them were clerked by registrars 121(83.4%) and senior registrars (7.6%). Seventy-eight (53.8%) had all aspects of their history documented accurately. Presenting complaint 141(97.2%) was the most accurately documented history and immunization history 104(71.7%) the least. There was an increase in the completeness of history obtained from children from 2.6% in 2017 to 44.9% in 2020. Registrars 66(84.4%) had more documented complete history compared to senior registrars (7.7%) and consultants (7.7%), P > 0.05. The least detailed history was obtained from children aged > 10 years (7.7%) compared to those under the age of five years (59%), P = 0.05.
Conclusion: There is a need for all doctors to go back to the basics of proper history taking and documentation for all children irrespective of age, being referred to the Paediatric Neurology Clinic.
Keywords: Accuracy, doctors, history, neurology clinic, paediatrics