Assessment of Adherence to Protocol in Medical Record Documentation in accordance with NABH Guidelines
Agency : Medical Record, NABH Guidelines, Audit Manual
Objective : The main objective of
this study was to study medical record department of the hospital, to audit
manual according to the NABH standards and to highlight major observations to
recommend implementable solutions.
Background : Not Available
Methodology : To enumerate
various types of forms in use in ward
areas, OPD, different clinical
department and laboratories a survey was done using Checklist – keeping in mind
the various quality standards, checklist was prepared
and filled by the data gathered, Interviewing the doctors and nursing
staff and the direct observation
of the functioning of various
departments. 130 records were audited
for the purpose of assessing medical records for proper documentation. Medical Records of 15 specialties were taken for the purpose
of audit. Out of the 347 in patients records 130 were picked up
(38%). Data analyzed using Microsoft excel.
Findings : It was found that many medical
records were not sufficiently well documented to provide
adequate evidence of continuity of care. It was
found that in the 4 various parameters assigned Admission request form, Doctors initial evaluation
form, condition of the discharge time
mentioned and birth certificate matter comes into the poor segment, whereas Elements
in medical records
and patients’ daily progress comes into the excellent parameter.
Recommendations : The study needs further exploration as to
identify the gaps in process flow department wise. For the same reasons the
forms should be redesigned and redundant columns should be done away with. MR contents
for discharged patients
should be arranged prior to filing.
And qualitative analysis
of MR contents should be done
a regular basis to monitor completeness of information. It is recommended that entries be recorded as closely as possible to the time of
the encounter, when the detail is most fresh in the physician’s mind.
This will allow physicians to deep records that are detailed, accurate and comprehensive.
to study medical record department of the hospital, to audit manual according to the NABH standards