Assessing documentation completeness of inpatient medical records at a Teaching Hospital in Lahore, Pakistan
An audit of documentation completeness of in-patient medical records
DOI:
https://doi.org/10.52442/jrmi.v12i2.1054Keywords:
Audit, Hospital Records, Inpatients, Medical Documentation, Medical Records, Patient CareAbstract
Introduction: Clinical audits serve as an important method to assess compliance with healthcare standards and promote quality improvement.
Objective: To identify gaps in documentation practices an audit was conducted to assess the completeness of inpatient medical records at a teaching hospital in Lahore, Pakistan.
Methodology: This cross-sectional audit employed a standardized checklist, based on guidelines of Islamabad Healthcare Regulatory Authority, Punjab Healthcare Commission and Royal College of Surgeons of England. All medical records from Department of Medicine (April to June 2025) were reviewed. Out of 141 retrieved files, 122 were analyzed (19 excluded due to damage/missing data). Data analysis was conducted using SPSS v23.
Results: Overall documentation completeness across all assessed items was 80.9% (95% CI: 79.7–82.1%). Basic demographics (name, age, gender, registration number) were fully documented. Address (90.9%), contact numbers (84.4%), presenting complaints (98.3%) and history of present illness (94.2%) were well documented. Occupation (18.8%) and weight (19.6%) were poorly recorded. Medication and family histories appeared in 78.6% and 93.4%. Psychiatric (6.5%), sexual (21.3%), and gynecological (10.6%) histories were rarely recorded. Diet/appetite (86%), travel (19.6%), and vaccination (28.6%) were inconsistently noted. Vital and focused examinations were complete, while other systems examinations were documented in 86.8%. Admission summaries (92.6%), problem lists (95.9%), and final diagnoses (98.3%) were mostly complete. Medications and follow-up plans were consistently documented; procedures/interventions appeared in 87.7%.
Conclusion: While documentation was strong in several areas, key gaps remain in patient history and auxiliary data, requiring ongoing efforts to improve clinical record-keeping standards.
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