MEDICALAUDIT OF INPATIENT MEDICAL RECORDS IN A TERTIARY CARE HOSPITAL

Abstract

INTRODUCTION: Medical record enable healthcare professionals to plan, evaluate a patient's treatment and ensures continuity of care. In a health care setting it is very crucial to maintain proper medical records as these documents are prerequisite for planning patient care and have legal ramications. Therefore, medical audit plays an important role in continuous quality improvement. AIM & OBJECTIVE:To carry out the Medical Audit of Inpatient Medical Records in a Tertiary Care Hospital and to identify the deciencies and to propose recommendations. MATERIAL & METHODS: It was a retrospective and descriptive study. The quality assessment was performed using a 54 Parameters tool divided into 9 domains of Protocols & Policies. The sample size of 220 case sheets from all departments was taken. RESULTS:In our study the time in initial notes was missing in (79%) and time in daily notes was missing in (83%).The diet recommended was not mentioned in (75%). In daily notes, specialist notes were missing in (59%). In the daily clinical progress charts, patient particulars were incomplete/ missing in (72%) while weight of the patient was not endorsed in (99%). In discharge slip, the International Classication of Diseases (ICD) is missing in (44%). Recommendations: A standard discharge document check list performa has been designed and to be attached with all case sheets of the hospital. CONCLUSION: Medical records are technically valid health records which provide documentary basis for planning patient care and treatment by the physician and are vital for legal purposes.