Introduction: A medical record enables healthcare professionals to plan and evaluate a patient’s treatment and ensures continuity of care among multiple providers. A study was conducted to do medical audit of documentation of inpatient medical record in a multispecialty hospital to assess whether the existing documentation procedure is as per laid-down policy.

Study design: Retrospective, descriptive study.

Study area: A 545 bed multispecialty hospital in medical ward, gynecology and obstetrics ward, surgical ward, ear, nose, and throat (ENT) ward, eye ward, pediatric ward, skin ward, and psychiatry ward.

Sample size: Systematic random sample of all inpatient medical records of select ward of last 12 months was done. Sample size was 320 case sheets, 40 from each department. The data collected were primary and the source was the discharge case files of the last 12 months available in the medical record section. The approach used for data collection was quantitative. The techniques applied were survey and observation. A structured checklist (audit tool) with 26 checklist points was developed keeping few of the quality indicators as the benchmark.

Findings: Gynecology and pediatric department records were not found appropriate. Psychiatry and dermatology dept record keeping was found appropriate as per laid-down policy. Planned care was not planned as per standard protocol in surgery department.

Recommendation: Sensitizing the clinical staff regarding the importance of proper documentation of the forms and hospital-wide standardization of the medical record keeping including admission and discharge summary. Rewarding the best performing department/unit and educating and training the responsible staff to make a complete record of every patient should be emphasized in the hospital. There should be monthly audit of the documentation procedure.

Conclusion: Medical records are technically valid health records that must provide an overall correct description of each patient’s details of care or contact with hospital personnel. Medical records form a very important and critical document in hospital. These records are vital for legal purposes and for future planning of the hospital medical care.

Keywords: Checklist, Documentation, Inpatient medical record, Medical audit.

How to cite this article: Singh MM, Patnaik S, Sridhar B. Medical Audit of Documentation of Inpatient Medical Record in a Multispecialty Hospital in India. Int J Res Foundation Hosp Healthc Adm 2017;5(2):77-83.

Source of support: Nil

Conflict of interest: None