MedNEXT J Med Health Sci (2022) Page 1 of 5 Availability legibility and adequacy of diagnosis as entered in bed head ticket in a base hospital Sri Lanka: a descriptive cross-sectional study Indika Wanninayake 1 * and H.S.R. Perera 2 1 University of Lincoln, UK. 2 Institute of Health Policy, Consultant In Community Medicine, Sri Lanka. *Corresponding author: Dr. Indika Wanninayake, University of Lincoln, UK. E-mail: indikakumara7490@yahoo.com DOI: https://doi.org/10.54448/mdnt22205 Received: 02-24-2022; Revised: 04-15-2022; Accepted: 04-20-2022; Published: 05-03-2022; MedNEXT-id: e22205 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. Keywords: Bed Head Ticket. Availability. Legibility. Adequacy. Diagnosis. Coding. Introduction Health information is used for planning, policymaking, resource allocation, teaching, training, medico-legal purposes, and research [1]. Health Information has two portions. They are hospital information and public health information. Medical Records are a vital part of the hospital information system [2]. In the Sri Lankan health care setting, episodes of inpatient hospital care are recorded in Bed Head Ticket (BHT). In these episodes, a patient may have taken patient treatment for acute/chronic illness, or undergone procedures. Bed Head Ticket (BHT) is a written collection of information about patients. It is defined as a compilation of pertinent facts of a patient’s life and health history, including past and present illness and treatments were written by the health professionals contributing to that patient’s care [3]. In the life cycle of a BHT Firstly, BHT is generated at the admission desk of the OutPatient Department. Patient identification data and admitting officers ’ notes are entered at admission. The numbering of the BHT is done according to a numbering system. BHT is sent toward with patient. Documentation is done thereafter, by medical professionals who attend to the patient. At the time of discharge, the final diagnosis is entered in block capital letters in the relevant space of the BHT by the medical officers including the intern house officer/Senior House Officer. Director-General of Health Services Ministry of Health Sri Lanka has instructed about procedures of medical records and hospital statistics by his circular no:01-05/99 of 26/02/1999. Hospital information storage is done through an internationally accepted coding system. Coding of the disease is done by Medical Record Officers (MROs) based on a diagnosis of the disease. As current activities and future developments of the hospital are based on accurate information. Therefore, priority should be given to the appropriate hospital information management process. Accurate coding is dependent on a comprehensive and accurately written diagnosis. Therefore, it is essential to enter a comprehensive and accurate diagnosis in the BHT. Writing DOI: 10.54448/mdnt22205 ORIGINAL ARTICLE