CLINICAL DOCUMENTATION BY PHYSICIANS AS FACTOR AFFECTING PATIENTS CARE MANAGEMENT IN NIGERIA

This research work clinical documentation by physicians as factor affecting patient care management in Nnamdi Azikiwe University Teaching Hospital Nnewi, was carried out in order to determine the problems associated with poor clinical documentation, to ascertain the level of effects of poor clinical documentation, and the effectiveness of computerized clinical documentation. It has been widely observed that most hospital physicians in the country today do not ensure  accurate clinical documentation which has affected the patient care management in so many ways, this is as a result of poor clinical documentation by physicians which includes: untrained physicians on the area of clinical documentation, illegible and unclear hand writing of the physicians, inadequate power supply, non standard abbreviation by the physicians, incomplete clinical documentation of the patients health information among others.