K H Tijani1, A O Lawal, R W Ojewola, T A Badmus. 1. Urology Unit, Department of Surgery, College of Medicine, University of Lagos, Lagos State. habeeb_tijani@yahoo.com
Abstract
BACKGROUND: Urethral catheterization is a common minimally invasive procedure with well-known complications some of which may be severe. Quite often, a clinician is invited to manage the short and long-term complications of the procedure without adequate records of the procedure itself. OBJECTIVES: This study aims to determine the quality of documentation of urethral catheterization in our health institution. METHODS: This prospective study was carried out over a period of 1 month. The documentations in the medical notes and nursing records with respect to urethral catheterisation were assessed using 10 different parameters with the aid of a pro-forma. Statistical analysis was done with the Wilcoxon signed ranks test. RESULTS: A total of 89 patients were catheterised in the wards, the emergency departments and the theatre. All the catheterizations were performed by doctors. The overall quality of documentation of catheterisation was poor: It was significantly worse in the medical notes than the nursing records with 28% of all cases documented by the nurses not documented by the physicians. Documentation in the theatre and emergency were worse, while there was no documentation of aseptic technique in any patient. An 11% incidence of complications was noted. CONCLUSION: The quality of record keeping concerning urethral catheterization was inadequate. This is important not only for patients' care, but also for medico-legal purposes. We therefore recommend regular audit and introduction of protocols for proper documentation.
BACKGROUND: Urethral catheterization is a common minimally invasive procedure with well-known complications some of which may be severe. Quite often, a clinician is invited to manage the short and long-term complications of the procedure without adequate records of the procedure itself. OBJECTIVES: This study aims to determine the quality of documentation of urethral catheterization in our health institution. METHODS: This prospective study was carried out over a period of 1 month. The documentations in the medical notes and nursing records with respect to urethral catheterisation were assessed using 10 different parameters with the aid of a pro-forma. Statistical analysis was done with the Wilcoxon signed ranks test. RESULTS: A total of 89 patients were catheterised in the wards, the emergency departments and the theatre. All the catheterizations were performed by doctors. The overall quality of documentation of catheterisation was poor: It was significantly worse in the medical notes than the nursing records with 28% of all cases documented by the nurses not documented by the physicians. Documentation in the theatre and emergency were worse, while there was no documentation of aseptic technique in any patient. An 11% incidence of complications was noted. CONCLUSION: The quality of record keeping concerning urethral catheterization was inadequate. This is important not only for patients' care, but also for medico-legal purposes. We therefore recommend regular audit and introduction of protocols for proper documentation.