An Audit of Documented Rehabilitees` Data at the Workers` Compensation Rehabilitation Centre (WCRC) in Bulawayo, Zimbabwe

Abstract

The primary objective of Workers’ Compensation Rehabilitation Centre is to provide clinical rehabilitation services to patients who have work related injuries. To do this, the centre requires complete rehabilitees’ data to be transmitted from the referrer to the centre as well as across internal departments for the centre. This is because documentation of medical records is a fundamental tool for communication between health professionals. It informs the care provided, treatment, care planned and the outcome of that care as a continuous and contemporaneous record. However, the researcher was not aware of any clinical audit of documented rehabilitees’ data with respect to compliance with this requirement. This prompted a review of rehabilitees’ data for its completeness as a vital initial step towards optimisation of rehabilitees’ care pathways. The research method was a non-participatory document review of quota sampled discharged rehabilitees’ files using a descriptive and analytical research design. Data were captured using a structured data collection instrument designed and tested by the experts in the medical fraternity. The instrument was designed from information prescribed in internationally referred documents and refined using information prescribed in the Procedures Manual for the centre. Generally, rehabilitees’ information was incomplete thereby making the referral and review of patients difficult. Clinical template forms in use at the research site had inadequate form fields and this was an important factor which modelled the level of completeness of rehabilitees’ information. These inadequate form fields resulted in important facts about the rehabilitees not efficiently transmitted across departments so much that there was practically no meaningful documented dialogue on balancing benefits with the risks to patients. There is need to revise the content of the procedure manual to prescribe that all clinicians file complete discharge rehabilitees’ information in one folder as part of improving documentation in line with the principle of medical care and international standards.