TY - JOUR AU - ., Ziauddin AU - Saeedi, Ilyas AU - Muhammad, Riaz AU - Mahmood, Khalid PY - 2012/09/24 Y2 - 2024/03/29 TI - MEDICAL RECORD DOCUMENTATION OF PATIENTS ADMITTED TO A MEDICAL UNIT IN A TEACHING HOSPITAL JF - Journal of Postgraduate Medical Institute JA - J Postgrad Med Inst VL - 26 IS - 4 SE - Original Article DO - UR - https://jpmi.org.pk/index.php/jpmi/article/view/1372 SP - AB - Objective To compare the standards of documentation with audit study 2005 and to determine that changes have been implemented.<br />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.<br />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.<br />Conclusion: No change was made in the previous five years and no steps of improvement have been implemented. ER -