Clinical audits and the state of record keeping in india.

Abstract

There is no legislative framework in India at the moment, which would enable collating data from hospitals on standard indicators of quality of patient care. It is only such data on patient care processes and outcomes, which would enable any meaningful audit of medical services with a view to making these services patient oriented.Hospital services should be such as to facilitate better patient outcomes and should be consistent with current professional knowledge. But without any data on quality of care indicators, there is no way to identify areas which need improvement and which could indeed enable patients to be better served. It is structured data on large numbers of patients from any specific institution over a reasonable period of time and also across institutions and adjusted for risk, which would enable care providers to identify and address lacunae. But without any law which says this should be done, it is only data which managements consider important which is captured. Many individual doctors also record data regarding their own patients but unless they have access to structured data about a larger patient set, it would be difficult to see why some patients in similar circumstances get better and others don’t.