Internal Quality Assurance in Clinical Documentation
Agency : Quality Assurance, Clinical Documentation, Quality of Documentation
Objective : The study was taken to examine and measure the quality of documentation in clinical areas.To
suggest remedial and
corrective/preventive actions to sustain the quality of documentation in clinical areas and to examine the effect of implementation the
preventive/corrective actions. The sole aim of the study is to identify
the areas to sustain or improve the
documentation process and to
recommend the methods to achieve
Background : Not Available
Methodology : First phase, all departments in the hospital was observed for the documentations process. Informal interview and group discussion was carried out with people
involved in the documentation.
Area of common mistakes and difficulties
faced by the department in clinical documentation was observed in detail. In second phase, a
check list is prepared based on non conformance/Partial conformance of
measurable elements which were identified during the NABH external assessment. Final phase, medical records
of the patient who are treated
in the hospital are audited
with the help of check list and the
data was analyzed. Major contributing factors are identified using pare to principle and recommendations for the same was formulated.
Findings : It was found that
94.6% of the medical officers are not
mentioning the time of assessment and reassessment. 91.9% Charge
nurse is not mentioning the date, time and signature in each valid medication
notes. General consent forms on admission were not duly signed by 89.3%.patient.
This was because patient
comes to inpatient department (wards) through the
emergency department, so during
filling the admission patients relatives
were signing the general consent form.
Recommendations : To enhance
the effectiveness and sustainability of internal quality assurance efforts,
internal hospital quality assurance program should encompass all the aspect of
the facility (not just one type of service) and aim from the outset to
construct a self sustaining QA system that does not depends on external support.
To examine and measure the quality of documentation in clinical areas.To suggest remedial and corrective/preventive actions to sustain the quality of documentation in clinical areas