This chapter presents the background of the study related to the context of Nigeria and Nigeria’s health system, and the quality of patient record-keeping. It outlines the problem statement related to the quality of patient record-keeping, and the aim and objectives of the study. It also describes the significance of the study and gives operational definitions of terms. Lastly, an outline of the thesis is presented.

Background to the study

Keeping patient records accurately provides a correct account of the treatment and care given to patients; this allows for good communication between nurses and midwives  as a team in their daily activities (Stevens & Pickering, 2010). Patients’ daily records, including the nursing records, are considered legal documents and must accurately and honestly reflect nursing actions carried out for the patients (Maharaj, 2015). Poor documentation potentially negatively affects patient care, professional accountability, and organisational risk (Blair & Smith, 2012). In addition, future improvement of nursing care depends on precise nursing information in the patient’s records; it is thus essential that nursing records be completed comprehensively and accurately. However, many countries across the world are experiencing problems in decision making, planning processes, and performance evaluation of healthcare programmes due to the poor quality of health data recording (Corrao et al., 2009).

The United States Department of Health and Human Services in 2006 reported that the ratio for missing medical records was 1:7 in health services institutions, which means that for every 7 patients one medical file is missing, due to the lack of quality patient record-keeping (Marutha,

2011). Problems of poor-quality health data, a low level of health information use and poor management of health information systems have also been reported in a systematic review of health data quality management and best practices at community and district levels in low- and middle-income countries (LMIC) (Ndabarora, Chipps & Uys, 2014).

Keeping a clear and accurate nursing record for each patient is one of a nurse’s day-to-day duties, as this is only one method to support a nurse to remember everything that has been done during a shift, in order to facilitate a clear and complete handover of patient information to the next team of nurses and midwives  (Stevens & Pickering, 2010).

According to the law in many countries, if care or treatment given to a patient is not accurately recorded, it can be taken that it has not been done (Stevens & Pickering, 2010). Records provide for accountability by offering a basis for continuity of care, evidence of changes in the patient’s condition and proof that care has occurred (McIntosh, 2008).

The South African Nursing Council (SANC) states that “the quality of nursing practice is founded on timely, accurate and complete recording of the care provided to patient” (McIntosh, 2008, 3 ). Furthermore, the South African Nursing Council Act 33 of 2005 indicates that a nurse may be disciplined if found negligent for not recording details of his or her nursing care (Mtsha, 2009).

Evidence in the literature has shown that poor record-keeping leads to failure of the healthcare system to deliver an efficient service (Marutha, 2011). Similarly, a study by Ngoepe (2012) revealed that poor record-keeping is one of the major factors contributing to negative audit reports.

In South Africa studies by Marutha (2011) and Chinyemba (2011) identified that many institutions in public health sectors in Limpopo Province and some other provinces are experiencing the same problems of poor quality of patient record-keeping.

According to Jefferies et al (2010: 113) study, state that traditionally nurses and midwives  communicate information more verbally about their patients, more so than confirming it in writing. In Tanzania a study conducted by Mamseri (2012, 107) on ‘The nursing process as a means of improving patient care’ revealed that nurses and midwives  often use verbal communication rather than written communication while reporting their patients’ care and conditions. The study identified that among 120 respondents, 31 (26%) agreed that they always use verbal communication, 59 (49%) indicated that nurses and midwives  sometimes use written communication, 18 (15%) reported that they rarely take care about written communication, and 12 (10%) were not at all if they always use verbal communication or sometimes use written communication.

In a study by Olivier (2010), revealed that there is an evidence correlation between the length of time following completion of training and reluctance to keep records. It means that with the more time lapsed, the least likely nurses and midwives  are to keep adequate records, and this should be the result of the lack of the current knowledge regarding nurse’s attitude related to terminology and record- keeping.

According to Saranto and Kinunen (2009: 465) study, standardised terminology is a pre-requisite for consistent communication, therefore certain skills and knowledge are essential to achieve this effective communication among health care providers. The action of record-keeping requires skills and knowledge as information is recorded in line with the steps of the nursing process of assessment, planning, implementation and evaluation (Mamseri, 2012).

However in Maharaj (2015) study, conducted in three hospitals in the Umgungudlovu District of KwaZulu-Natal, South Africa, confirmed that a shortage of nurses and midwives , non-use of support staff per nursing unit, bed occupancy rate and type of unit, including type of hospital, are the greatest barriers hindering the quality of patient information recording and processing. Other major factors are lack of awareness about the proper filing systems, lack of training and of knowledge, and practical skills of nursing staff in patient information record-keeping (Marutha, 2011)

Nigeria is experiencing nurses and midwives ’ complaints about workload (Carlsson et al., 2014) and has a continuously decreasing investment in education and research activities (Klopper & Gasanganwa, 2015). There is limited information regarding the quality of patient information recording in clinical settings in Nigeria.