Assessment of the Quality of Diagnosis Documentation in Bed Head Ticket in a Selected Ward of a District General Hospital in Sri Lanka

Abstract: Effective planning, policy making, and decision making depend on the availability of accurate hospital information. Hospital information storage is done though international accepted International Classification of Disease 10threvision. Accurate diagnosis is vital for accurate 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 of the study was to assess the quality of documentation in Bed Head Ticket in a ward of the District General Hospital Sri Lanka. One of the medical wards randomly selected for the study. Descriptive cross-sectional study was done to achieve objective. Three hundred eighty-four BHTs of selected ward belonged to the last quarter of 2025, were assessed by using data extraction sheet to check that diagnosis are according to the circular No-01-05/99. Out of 384 BHTs diagnosis was available in 350(91%) BHTs meanwhile legibility to read was 339 among available BHTs. In 32(9.5%) BHTs were written block capital letters as in circular 01-05/99 of 26/02/1999. Abbreviations were used to write diagnosis in 130 BHTs (38.3%). As current activities and future developments of the hospital are based on accurate information. Therefore, priority should be given to appropriate hospital information management process. Accurate coding is dependent on comprehensive and accurately written diagnosis. Therefore, it is essential to enter comprehensive and accurate diagnosis in the BHTs. An interventional package to improve documentation of diagnosis and further comprehensive studies on improving quality of diagnosis documentation are recommended. Keywords: Bed Head Ticket, Diagnosis, Availability, Legibility, Adequacy). Title: Assessment of the Quality of Diagnosis Documentation in Bed Head Ticket in a Selected Ward of a District General Hospital in Sri Lanka Author: Indika Wanninayake, Jayani Marasinghe, Sucharitha Dharmasena International Journal of Recent Research in Commerce Economics and Management (IJRRCEM) ISSN 2349-7807 Vol. 13, Issue 2, April 2026 - June 2026 Page No: 52-54 Paper Publications Website: www.paperpublications.org Published Date: 14-April-2026 DOI: https://doi.org/10.5281/zenodo.19564611 Paper Download Link (Source) https://www.paperpublications.org/upload/book/Assessment%20of%20the%20Quality-14042026-1.pdf