MEDICAL RECORD DOCUMENTATION OF PATIENTS ADMITTED TO A MEDICAL UNIT IN A TEACHING HOSPITAL

Objective To compare the standards of documentation with audit study 2005 and to determine that changes have been implemented. Methodology This descriptive audit study was conducted in the medical C unit of Lady Reading Hospital, Peshawar - Pakistan from 1st January 2010 31st December 2010. Out of 3684 patients admitted during the year2010. 200 case notes were randomly selected and subjected to re-audit. The clinical notes were broadly analysed for documentation of six parameters. Each parameter s documentation was to be graded as very good, good, average, poor or not documented. Results: Personal bio-data was documented average in 195(97.5%) cases; History and examination were average in 98(49%) cases and good in 85(42.5%) cases; Investigations were documented good in 140(70%) and average in 13(6.5%) cases. progress notes were good in130(65%)cases and treatment was documented good in194(97%)cases.In105(52.5%)charts, one or more of the six selected items were not documented at all. Progress notes were not written in 48(24%), investigations in35 (17.5%).diagnosis in16 (8%), history and examination in4(2%),bio-data in 2(1%)and treatment in1(0.5%) of the case notes. For comparison between audit 2005 and present audit 2010,the P value was 0.05. Conclusion: No change was made in the previous five years and no steps of improvement have been implemented.