Toll Free for Admission 1800-3010-5700

Internal Quality Assurance in Clinical Documentation


  • Thirumalai N
  • 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 them.
  • 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