AUDIT OF PATIENTSâ€™ RECORD KEEPING FILES IN GYNAECOLOGY AND OBSTETRICS WARD OF REHMAN MEDICAL INSTITUTE, PESHAWAR
Keywords:Medical Audit; Nursing Audit; Quality Assurance; Medical Records; Hospital Records.
Introduction: Unfortunately, the standard of care, sense of responsibility among junior doctors, and efficacy and honesty is deteriorating day by day not only in public sector hospitals but also in private hospitals. This audit was done to know how far our record keeping is correct and up to date.
Materials & Methods: Medical audit of patient record files was carried out in the Department of Ob/Gyn of Rehman Medical Institute (RMI) from October 01to October 31, 2016, including both booked and emergency cases. The records of 209 patients who were admitted during this month were reviewed. The files of these patients were assessed daily upon discharge based on a checklist containing patient age, husband name, date and time of admission, findings of history and examination, procedure notes, daily progress notes, and notes signed by the doctor. Data analysis was performed through SPSS 15.0 for descriptive statistics.
Results: It was noted that most of the demographic entries of patients were missing; in 40% cases, ages of patients were not mentioned, and in 84% files the names of husbands were missing. The Obstetric history was incomplete in 15% cases, but the examination findings were written in 100% cases; 17% of patient files were not signed by doctors. The daily program reports were entered 100%.
Conclusion: The audit indicates that complete documentation of patients is essential for evidence of good clinical practice. This audit has an impact on the performance of Ward D staff as well, hence they will realize improvement in their conduct.