A Review of Admission Records of Neonatal Unitof Bingham University Teaching Hospital, Jos. Plateau State, Nigeria.

Abstract

Background: Clerking is the first and most important procedurewhich a doctor has at first contact with a patient or patients’ relations. This provides an opportunity for the physician to obtain vital data which on documentation forms the initial records of the patient which may not be available later. The aim of the study was to assess the clerking of preterm babies admitted into the neonatal unit of the hospital. Methods: A retrospective study on all the preterm babies that were admitted into the neonatal unit of the hospital from January 2018 -December 2018. Results: A total of 324 babies were admitted into the unit during the period under review. Preterm babies made up 29.3% (95) of the total admissions. Male to female ratio of 1:1.2. No sex recording for 1% of them, no gestational age recorded for 25% of the preterm babies and no mothers age, parity, religion, job and tribe in 47%, 40%, 3%, 60% and 10% respectively. The risk factor for prematurity that was most documented were estimated gestational age (EGA) and history of maternal fever with 74% and 75% respectively, while the least documented were the maternal weight gain and Packed Cell Volume (PCV) with 0% record. Diagnosis was recorded in 100% of cases. However, some important information waslacking on risk factors. Conclusion: The documentation on prematurity clerking weredeficient in some important biodata and risk factors. There is room for improvement.