Abstract
Background: Emergency Departments (EDs) receive a
variety of patients with different exigent and challenging
health conditions. This almost always puts the staff within
the department under intense pressure which could
adversely affect proper documentations and record
keeping. To this end, we conducted a one-year (01 January
to 31 December, 2019) review of ED patient case records.
Objective: The objectives of the study were to determine
the pattern of presentation and missing diagnoses on
patients’ case records at the ED.
Methods: A retrospective review of records of all patients
who presented at the ED within the period of study was
done. Data for the review included demography and
diagnosis by attending emergency physicians. All cases
in which a diagnosis was not recorded in the ED treatment
card were categorized under missing a diagnosis and those
with percentages less than 0.1 were grouped as other
diagnoses.
Results: A total of 9,880 patients were attended to in 2019.
About half (4,868/9880, 49.3%) were males while (4,987/
9880, 50.5%) were females with a small number without
gender specified (25/9880, 0.2%). The median age of the
patients was 38 years with inter-quartile range of 27 to 54
years. Medical emergencies were the leading types of
emergencies (5737/9880, 58.1%) followed by surgical
emergencies (3047/9880, 30.8%). The five leading
diagnoses were cardiovascular diseases (1057/9880,
10.7%), Road Traffic Accidents (951/9880, 9.6%), Malaria
(802/9880, 8.1%), Head Injury (408/9880, 4.1%) and
Fractures (408/9880, 4.1%). A high percentage of missing
a diagnosis (1260/9880, 12.8%) was recorded.
Conclusion: Our study revealed a high number of diverse
cases at the ED from January to December, 2019. The
largest proportion of patients was in the age group of 21
to 40 years (40.9%). Medical emergencies were the
commonest (58.4%) presentation, with cardiovascular
emergencies predominating. A proportion (1260/9880,
12.9%) of the documentation was missing a diagnosis.
There is the need to improve on the accuracy of
documentation and efficiency delivery in the Emergency
Department. It is also a pointer to the need to rapidly
scale up the current deployment of electronic medical
records systems in the hospital.
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