A study to rationalize the health-care (clinical and medical) record forms in use at SGPGIMS hospital, in conformance with inter/national guidelines, so as to ensure structural and contextual uniformity while updating the same for prospective in-house consumption by the end users

Abstract

Background: Effectual management of medical records (MR) is a prime component in health-care delivery organizations. A standardized medical form facilitates for obtaining comprehensive information along with appropriate documentation for swift and efficient retrieval of information pertaining to the quality of patient care. It seems astounding that hitherto, there have been no set standards/criteria to evaluate MR forms. With this backdrop, the study aimed to rationalize MR forms in use at SGPGIMS in conformance with the inter/national guidelines as a stride toward quality improvement.Aim: The aim of this study was to rationalize the health-care (clinical and medical) record forms in use at SGPGIMS hospital, in conformance with inter/national guidelines, to ensure structural and contextual uniformity while updating the same for prospective in-house consumption by the end user.Objectives: The objective of this study was to obtain the health-care (clinical and medical) record forms in use at SGPGIMS hospital. To compare the health-care (clinical and medical) record forms in use at SGPGIMS hospital with inter/national guidelines through the appropriate designed tool, i.e., (structured checklist). To recommend an evidence-based modification in health-care (clinical and medical) record forms based on analysis of data obtained, to ensure structural and contextual uniformity while updating the same for the prospective in-house users, if required.Methodology: A descriptive study was carried out at Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, with a study sample of preidentified health-care (clinical and medical) forms which are the core forms to all the departments of SGPGIMS, hospital. A customized validated tool kit (structured checklist) was designed in conformance with inter/national guidelines to assess the preidentified health-care (clinical and medical) forms.Results: The Medical Certificate of Cause of Death Form was found to have the highest compliance rate of 90.5% with the given set of parameters among the preidentified forms, while the Medication Chart and Assessment Form have noncompliance rates of 61.1% and 58.1%, respectively, with the given set of parameters. Rest other preidentified medical forms have the noncompliance rate of <50% with the given set of parameters of customized tool kit.Conclusion: Since this was the foremost study conducted, it was observed that there was a need to rationalize the MR forms by implementing the observations made, so as to ensure structural and contextual uniformity by the end users.