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Report on Departmental Audit Cycle Analysis


  • Kusum Priti Lakra
  • Agency : Max Health care, NABH, Accrediation, , Departmental Mannuals
  • Objective : Departmental Audit cycle Analysis is a retrospective study ,aimed in identifying the GAPs and finding the solution for the GAPs closure to enhance the functioning of the department and strengthening the process.
    Out of the four major departments, Medical record department was chosen for the research study. There are total 15 units of Vaatsalya spread all across the North Karnataka ,South Karnataka and Andhra Pradesh .The data for the last quarter of the 9 units of the MRD department was studied to identify the GAPs and the overall lower % compliance for the each unit .
    Initially the qualitative data of all the 9 units were converted into quantitave data using excel and the result was subdivided into poor (<50%), partial (50-80%) and good compliance (>80%) based on their compliance rating.
    The 13 parameters of the checklist was analyzed for all the 9 units using Pareto Analysis .Out of 13 parameters three parameters which were the majors areas of concerns were: Consent Forms, Discharge Summary& Medical Record case Register.
    Findings were as follows: Out of the total 9 units, 8 units has compliance % <50 except for Mysore whose compliance rate was >80% due to the availability of anaesthesia consent forms .The cause of poor compliance was also identified, by doing the root cause analysis and it was found that due the unavailability of the desired consent forms and formats which were specified in the checklist the respective unit was not performing well.
    It was also found that, the discharge summary was incomplete. The discharge summary was not specifying the following findings: significant finding, patient condition at the time of discharge, contact number of the treating doctors and this was one of the reasons for the poor performance. Out of the 9 units none had compliance >80%, only two units had partial compliance (50-80%) and the units were Hassan and Tarikerre. It was also found that, only two units (Mysore and Hassan) out of 9 units had separate MLC register and police intimation register for Medico legal case. Another finding was that, for DAMA Case some of the parameters like reason for DAMA were not being captured and because of that the compliance % of the unit was declining. The identified GAPs were highlighted and necessary steps were initiated. After discussing with the head of the concerned department the required consent forms were formulated and rolled out in the units.
    One day training program was conducted for the MRD Technician and training were given regarding importance of Medical Record and also regarding Medical case sheet maintenance &storage. At last, the MRD previous checklist was revised and new checklist was formulated and rolled out in different units to evaluate the % compliance
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Departmental Audit cycle Analysis is a retrospective study ,aimed in identifying the GAPs