Effect Of Improper Documentation Of Health Records

ABSTRACT Documentation in medical record is the basis for communication between health professionals which inform the care provided, the treatment rendered, care planned and the outcome of that care as a continuous and existing record. Health information documentation is a document about healthcare services that is provided to an individual patient. If documentation doesn’t give a clear presentation of a patient’s history, it is termed improper documentation. Thus, this study aims to determine the level of patient documentation practice and ascertained the technical knowledge possessed by heal…