CHAPTER ONE

1.0       INTRODUCTION

Modern health care is mainly delivered through hospital that are established to meet the need of patient, Benjamin (2016), defined hospital as a diagnostic  and treatment facility providing  board and lodging medical care and continuous nursing care for alleviation or care of illness or injury to outpatient, in-patient and emergency patients in health care facilities.

He added that, the facilities must have at least one physician as the permanent staff to make provision for in-patient to remain at least 18 -20 hours and maintain clinical records on all patients.

Health information management is very important in the management and treatment of patient,

Ejale (2014), defined health records “as compilation of pertinent fact of a patient life history including past and present illnesses and treatment written by health practitioners contributing to patient care” he also states that health record must be compiled in a timely manner and should contain sufficient information to identify the support for diagnosis or reason for health care encounter to justify the treatment and ensure accurate documentation of  the result.

 In addition, Meegreal (2011), defined health information management as “an orderly written document encompassing the patient identification data ,health history, physical examination findings, laboratory report, diagnosis treatment, surgical procedure and hospital courses “according to him the purpose of health records are to provide means of communication among physician ,nurses and allied health care professionals, to serve  as easy reference  for providing continuity in patient care, to furnish documentary evidence of care provided in health care facilities ,to serve as informational document to assist the quality of patient care, to protect the physician and health care institution and its employees in the event of litigation, to supply pertinent care information to authorized organization and third party payers.

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