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MedNext Journal of Medical and Health Sciences
Articles
DOI: 10.54448/mdnt22205
Submitted: 20-04-2022
Published: 25-04-2022

Availability legibility and adequacy of diagnosis as entered in bed head ticket in a base hospital Sri Lanka: a descriptive cross-sectional study

University of Lincoln, UK
Institute of Health Policy, Consultant In Community Medicine, Sri Lanka
Bed Head Ticket Availability Legibility Adequacy Diagnosis Coding

Abstract

Introduction: Hospital information storage is done through an internationally accepted coding system. It is very important to have an accurate diagnosis for proper coding. Ministry of Health has issued a circular (No-01-05/99) for the documentation of Bed Head Ticket (BHT) including writing the correct diagnosis.  Objective: To assess the availability, legibility, and adequacy of diagnosis as entered in the BHTs of selected wards in a base hospital in Sri Lanka. Methods: Descriptive cross-sectional study was conducted to assess availability, legibility, and adequacy of diagnosis as entered in 384 BHTs of selected wards in a Base Hospital in Sri Lanka. A data Extraction sheet (DES) was used as a study instrument.  Results: Out of 384 BHTs diagnosis were not available in 12 (3.13%) BHTs and diagnosis were illegible in 36(6.99%) BHTs. In 244(67.59%) BHTs diagnosis were written as abbreviations. Only in136(37.46%) BHTs, diagnosis were written in block capital letters. Conclusion and recommendation: Documentation diagnosis in the BHTs is not according to the standards. Therefore, medical administrators, policymakers, and clinicians should take urgent actions to improve documentation diagnosis in BHTs.

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How to Cite

Wanninayake, I., & Perera, H. S. R. (2022). Availability legibility and adequacy of diagnosis as entered in bed head ticket in a base hospital Sri Lanka: a descriptive cross-sectional study. MedNEXT Journal of Medical and Health Sciences, 3(2). https://doi.org/10.54448/mdnt22205