MEDICAL RECORD DOCUMENTATION OF PATIENTS ADMITTED TO A MEDICAL UNIT IN A TEACHING HOSPITAL
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Keywords:
Case notes, Patient information, Documentation, Change
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Abstract
Objective To compare the standards of documentation with audit study 2005 and to determine that changes have been implemented.
Methodology This descriptive audit study was conducted in the medical C unit of Lady Reading Hospital, Peshawar - Pakistan from 1st January 2010 31st December 2010. Out of 3684 patients admitted during the year2010. 200 case notes were randomly selected and subjected to re-audit. The clinical notes were broadly analysed for documentation of six parameters. Each parameter's documentation was to be graded as very good, good, average, poor or not documented.
Results: Personal bio-data was documented average in 195(97.5%) cases; History and examination were average in 98(49%) cases and good in 85(42.5%) cases; Investigations were documented good in 140(70%) and average in 13(6.5%) cases. progress notes were good in130(65%)cases and treatment was documented good in194(97%)cases.In105(52.5%)charts, one or more of the six selected items were not documented at all. Progress notes were not written in 48(24%), investigations in35 (17.5%).diagnosis in16 (8%), history and examination in4(2%),bio-data in 2(1%)and treatment in1(0.5%) of the case notes. For comparison between audit 2005 and present audit 2010,the P value was 0.05.
Conclusion: No change was made in the previous five years and no steps of improvement have been implemented.
Methodology This descriptive audit study was conducted in the medical C unit of Lady Reading Hospital, Peshawar - Pakistan from 1st January 2010 31st December 2010. Out of 3684 patients admitted during the year2010. 200 case notes were randomly selected and subjected to re-audit. The clinical notes were broadly analysed for documentation of six parameters. Each parameter's documentation was to be graded as very good, good, average, poor or not documented.
Results: Personal bio-data was documented average in 195(97.5%) cases; History and examination were average in 98(49%) cases and good in 85(42.5%) cases; Investigations were documented good in 140(70%) and average in 13(6.5%) cases. progress notes were good in130(65%)cases and treatment was documented good in194(97%)cases.In105(52.5%)charts, one or more of the six selected items were not documented at all. Progress notes were not written in 48(24%), investigations in35 (17.5%).diagnosis in16 (8%), history and examination in4(2%),bio-data in 2(1%)and treatment in1(0.5%) of the case notes. For comparison between audit 2005 and present audit 2010,the P value was 0.05.
Conclusion: No change was made in the previous five years and no steps of improvement have been implemented.
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1.
. Z, Saeedi I, Muhammad R, Mahmood K. MEDICAL RECORD DOCUMENTATION OF PATIENTS ADMITTED TO A MEDICAL UNIT IN A TEACHING HOSPITAL. J Postgrad Med Inst [Internet]. 2012 Sep. 24 [cited 2024 Dec. 22];26(4). Available from: https://jpmi.org.pk/index.php/jpmi/article/view/1372
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