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Assessment of Adherence to Protocol in Medical Record Documentation in accordance with NABH Guidelines


  • Natasha Ahmad
  • 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