Documentation of Inpatient Medical Records: A Clinical Audit

Abstract

Background: Effective documentation is essential for ensuring high-quality clinical practice. Medical notes serve as a crucial form of communication among all those who are involved in a patient’s care. Therefore, it is important to have a quality assurance mechanism in place to ensure that medical records comply with established standards. Objective: To evaluate the quality of medical notes writing in different departments of Mangail Teaching Hospital, and to implement some possible solutions to improve the quality of existing medical records and overcome the deficiencies. Methodology: A retrospective, prospective observational audit carried out in Managil Teaching Hospital, we included 108 files in both audit cycles, 54 in each. Sampling was done through a systematic simple random sampling method over a period of one week for every cycle. Data were collected and each file was compared to the Royal College of Physician standards, the collected data were entered into an Excel sheet, cleaned then analyzed using Statistical Package for Social Sciences (SPSS) version 25 using frequency tables test. Results: A total of 108 samples were included. In the 1st cycle only 16.1% of doctors wrote the patient’s occupation, and 14.3% wrote the contact number, regarding the history section only 41.1% documented the patient’s history of presenting complaint. In the 2nd cycle, 74% documented the occupation, 76% wrote the contact number. One hundred percent have documented the patient’s history of presenting complaint. The overall impression was excellent in 0% in the 1st cycle and 55.6% in the 2nd cycle. Conclusion: Documentation practice in our teaching hospital did not meet the standards and the evaluating parameters used in the assessment showed high percentage of poor and unsatisfactory practice during the 1st cycle, however after a series of medical practitioner’s orientation a significant improvement was observed regarding inpatient medical records filling. Keywords: medical records, clinical audit, quality improvement