Abstract of Dissertation

Keyword : In-patient files; Compliance; Clinical Audit

Objective : The Objective of the study is to find out the compliance of in- patient documents among the staff of hospital using a self-designed data collection tool and to compare the difference between the compliance of in- patient records and the standard compliance set by the hospital.

Background : Aim: Proper Documentation of medical files on time is very important in hospital settings and the aim of the study is to do audit to ensure that all clinical records are maintained to the highest standard as well as providing a benchmark to continually improve the quality and accuracy of clinical records.

Methodology : Descriptive study was conducted on admitted patient’s medical file to understand the activities and identify the problems. Primary data was collected from the medical files. Data collection tool was self-designed Excel sheet with 30 headings and analysis was done in MS Excel only.

Findings : The study shows large amount of missing data in medical files; OPD documentation (having compliance 90%), emergency documentation (found in 47% of files), IPD documentation (found in 81% of files) and operation theatre documentation (founds in 71%), whereas overall compliance of in-patients file is 74%.