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10.5005/jp-journals-10035-1080
Medical Audit of Documentation of Inpatient Medical Record in a Multispecialty Hospital in
ORIGINAL ARTICLE

Medical Audit of Documentation of Inpatient Medical

Record in a Multispecialty Hospital in India
1
Madhav M Singh, 2Saroj Patnaik, 3Bhandaru Sridhar

ABSTRACT Keywords: Checklist, Documentation, Inpatient medical record,

Introduction: A medical record enables healthcare profession- als Medical audit.
to plan and evaluate a patient’s treatment and ensures con- tinuity of How to cite this article: Singh MM, Patnaik S, Sridhar B.
care among multiple providers. A study was conducted to do Medical Audit of Documentation of Inpatient Medical Record in a
medical audit of documentation of inpatient medical record in a Multispecialty Hospital in India. Int J Res Foundation Hosp Healthc
multispecialty hospital to assess whether the existing documentation Adm 2017;5(2):77-83.
procedure is as per laid-down policy.
Source of support: Nil
Study design: Retrospective, descriptive study.
Conflict of interest: None
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
INTRODUCTION
ward.
Sample size: Systematic random sample of all inpatient medical A medical record enables healthcare professionals to
records of select ward of last 12 months was done. Sample size was plan and evaluate a patient’s treatment and ensures
320 case sheets, 40 from each department. The data col- lected were continuity of care among multiple providers.1 The
primary and the source was the discharge case files of the last 12
quality of care a patient receives depends directly on
months available in the medical record section. The approach used
for data collection was quantitative. The techniques applied were the accuracy and legibility of the information the
survey and observation. A structured checklist (audit tool) with 26 medical record contains.2 Maintaining a complete
checklist points was developed keeping few of the quality record is important not only to comply with licensing
indicators as the benchmark. and accreditation requirements, but also to enable a
Findings: Gynecology and pediatric department records were not healthcare provider to establish that a patient received
found appropriate. Psychiatry and dermatology dept record keeping adequate care.3
was found appropriate as per laid-down policy. Planned care was
Clinical audit is a quality improvement process that
not planned as per standard protocol in surgery department.
seeks to improve patient care and outcomes through
Recommendation: Sensitizing the clinical staff regarding the
systematic review of care against explicit standards/
importance of proper documentation of the forms and hospital-wide
standardization of the medical record keeping including admission criteria and the implementation of changes in practice
and discharge summary. Rewarding the best performing if needed.4
department/unit and educating and training the responsible staff to The definition of clinical audit as per the National
make a complete record of every patient should be emphasized in Institute of Clinical Excellence (NICE): “A quality
the hospital. There should be monthly audit of the documentation
improvement process that seeks to improve patient
procedure.
care & outcomes through systematic review of care
Conclusion: Medical records are technically valid health records
against explicit criteria and the implementation of
that must provide an overall correct description of each patient’s
details of care or contact with hospital personnel. Medical records change”.5
form a very important and critical document in hospital. These
records are vital for legal purposes and for future planning of the AIMS AND OBJECTIVES
hospital medical care.
Medical audit of documentation of inpatient medical
record in a multispecialty hospital.
1
Assistant Registrar, 2MO (HS), 3DDG (HR) • To assess whether the existing documentation
proce- dure is in accordance with the policy
1
Military Hospital, Meerut, Uttar Pradesh, India
established by the hospital.
2
OIC Pay cell, O/O DGAFMS, New Delhi, India
• To identify the lacunae in the same and to propose
3
O/O DGAFMS, New Delhi, India some possible solutions.
Corresponding Author: Saroj Patnaik, MO (HS), OIC Pay cell
O/O DGAFMS, New Delhi, India, e-mail: patnaik.saroj@gmail.com
MATERIALS AND METHODS

International Journal of Research Foundation of Hospital & Healthcare Administration, July-December 2017;5(2):77-83 1
Study Design
Retrospective, descriptive study.

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Medical Audit of Documentation of Inpatient Medical Record in a Multispecialty Hospital in

Study Area
documentation in correct section; investigations: pres-
A 545 bed multispecialty hospital in medical ward, ence of documentation in correct section; diagnosis:
gyne- cology and obstetrics ward, surgical ward, ENT presence of documentation in correct section;
ward, eye ward, pediatric ward, skin ward, and treatment: presence of documentation in correct
psychiatry ward. section; attend- ing doctor: named doctor documented;
procedures: procedures noted in correct section;
Sample Size summary-of-a-day: 1st, 2nd, and 3rd named doctor on-
Systematic random sample of all inpatient medical call. Follow-up was measured but excluded from the
records of last 12 months. Sample size was 320 case final primary outcome analysis as it is often completed
sheets, 40 from each department. at a different time to the rest of the inpatient book.
The following records were assessed for complete-
ness of documentation: admission information (date Data Collection
of admission and serial number), demographics (age, The data collected were primary and the source was
sex, and patient number), history, examination, inves- the discharge case files of the last 12 months available
tigations, diagnosis, and treatment, attending doctor, in the medical record section. The approach used for
procedures, summary-of-a-day, and follow-up. Other data col- lection was quantitative. The techniques
information checked to find out admission information: applied were survey and observation. A structured
serial number and date of admission; demographics: checklist (audit tool) was developed (Table 1) keeping
age, sex, and hospital number; history: presence of few of the quality indicators as the benchmark.
docu- mentation in correct section; examination:
presence of

Table 1: Checklist for clinical audit of medical records of inpatients

Clinical audit checklist Yes No
The hospital management develops an approach to improve accuracy of patient identification (identity proof) Medical
record/health information retention and disposal policy is available, implemented, and monitored Medical record
destruction log-book is maintained and retained with all mandatory entries as recommended in hospital policy document
Hospital management has developed clearly defined informed consent policy and procedure for general and specific
healthcare procedures
The care provided to each patient is planned and written in the patient’s record by the health professional providing the care
The care for each patient is planned by the responsible physician, nurse, and other health professionals within 24 hours of
admission to the hospital
The plan is updated or revised, as appropriate, based on the reassessment of the patient by the care providers Orders are
written when required, are legible, and follow organization policy
All patients have an order for food in their record
The order is based on the patient’s nutritional status and needs
The hospital management respects patient health information as confidential
Hospital management has developed and implemented policies and procedure to prevent the loss or misuse of patient
information. There is evidence of monitoring
Patient records contain a copy of the discharge summary with all mandatory elements
Discharge summary is prepared at discharge by a qualified individual
Patient’s referral/transfer policy, procedure, and referral forms are developed in accordance with hospital policy on patient
referral
All inpatients have an initial assessment(s) which includes an evaluation of physical, psychological, social, and economic
factors and all assessment must be documented legibly
The entries in the medical record must contain; Numeric date (D/M/Y)
• Numeric time
• Name with stamp
• Appropriate initials of care provider
Patient care record must be maintained/kept in their individual folders
Alteration or correction in the medical record must remain legible by using a single line to score out the information to be
corrected
Medical records must not include abbreviations other than those approved, published, and made available to all staff All the
discharge summary contains details of
• Summary of diseases
• Treatment given
(Cont’d…)

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Medical Audit of Documentation of Inpatient Medical Record in a Multispecialty Hospital in

(Cont’d…)
Clinical audit checklist Yes No
• Follow-up instruction
• Instruction for patient
Discharge summary contains ICD number
Discharge summary contains signature of treating physician/surgeon MLC
initiated in all cases where it should initiated
LAMA patients have given their unwillingness of treatment
Lab investigation form duly filled and entered in case sheet
ICD: International Classification of Diseases; MLC: Medicolegal case; LAMA: Leaving against medical advice

OBSERVATIONS AND DISCUSSION

most of the departments, notably in gynecology
There is clearly a large discrepancy between the depart- ment (25%). Leaving against medical advice
standard of record keeping in various departments. (LAMA) patients were discharge without taking
Psychiatry department was found to be best while unwillingness for treatment certificate in pediatric
gynecology and pediatric departments were found not (10%) and gynecology department (5%) patients.
satisfactory. Planned care was not provided to the International Classification of Diseases number was
patients as per stan- dard protocol in surgical and not found in gynecology (40%) and skin (20%) patients’
psychiatric wards as shown in Table 2. Almost all discharge. Discharge summary was not found duly
departments (5–10%) were not documenting the food completed in gynecology, eye, and pediatric wards
order in the medical records. Entry in medical record (20%). Alteration in medical records was found in
for date/name/sign was not present in almost all the departments.

Table 2: Various department-wise findings

Gynecology
and ENT Eye Skin
Medical obstetrics Surgical ward ward Pediatric ward Psychiatry
Clinical audit checklist ward (40) ward (40) ward (40) (40) (40) ward (40) (40) ward (40)
The hospital management develops an Yes Yes Yes Yes Yes Yes Yes Yes
approach to improve accuracy of patient
identification (identity proof)
Medical record/health information Yes Yes Yes Yes Yes Yes Yes Yes
retention and disposal policy is available,
implemented, and monitored
Medical record destruction log-book is Yes Yes Yes Yes Yes Yes Yes Yes
maintained and retained with all mandatory
entries as recommended in hospital policy
document
Hospital management has developed Yes Yes Yes Yes Yes No No No
clearly defined informed consent policy and
procedure for general and specific healthcare
procedures
The care provided to each patient is planned Yes: 32 Yes: 31 Yes: 28 Yes: 34 Yes: 36 Yes: 32 Yes: 34 Yes: 30
and written in the patient’s record by the health No: 8 No: 9 No: 12 No: 6 No: 4 No: 8 No: 6 No: 10
professional providing the care (Graph 1)
The care for each patient is planned by the Yes Yes Yes Yes Yes Yes Yes Yes
responsible physician, nurse, and other
health professionals within 24 hours of
admission to the hospital
The plan is updated or revised, as Yes: 30 Yes: 32 Yes: 30 Yes: 32 Yes: 30 Yes: 32 Yes: 36 Yes: 38
appropriate, based on the reassessment of No: 10 No: 8 No: 10 No: 8 No: 10 No: 8 No: 4 No: 2
the patient by the care providers (Graph 2)
Orders are written when required, are legible, Yes Yes Yes Yes Yes Yes Yes Yes
and follow organization policy
All patients have an order for food in their Yes: 31 Yes: 30 Yes: 34 Yes: 30 Yes: 32 Yes: 32 Yes: 32 Yes: 30
record (Graph 3) No: 9 No: 10 No: 6 No: 10 No: 8 No: 8 No: 8 No: 10
The order is based on the patient’s nutritional Yes: 31 Yes: 30 Yes: 34 Yes: 30 Yes: 32 Yes: 32 Yes: 32 Yes: 30
status and needs No: 9 No: 10 No: 6 No: 10 No: 8 No: 8 No: 8 No: 10
(Cont’d…)
International Journal of Research Foundation of Hospital & Healthcare Administration, July-December 2017;5(2):77- 7
 Madhav M Singh et

(Cont’d…)
Gynecology
and ENT Eye Skin
Medical obstetrics Surgical ward ward Pediatric ward Psychiatry
Clinical audit checklist ward (40) ward (40) ward (40) (40) (40) ward (40) (40) ward (40)
The hospital management respects patient Yes Yes Yes Yes Yes Yes Yes Yes
health information as confidential
Hospital management has developed Yes Yes Yes Yes Yes Yes Yes Yes
and implemented policies and procedure
to prevent the loss or misuse of patient
information. Evidence of monitoring
Patient records contain a copy of the discharge Yes Yes Yes Yes Yes Yes Yes Yes
summary with all mandatory elements
Discharge summary is prepared at discharge Yes Yes Yes Yes Yes Yes Yes Yes
by a qualified individual
Patient’s referral/transfer policy, procedure, and Yes Yes Yes Yes Yes Yes Yes Yes
referral forms are developed in accordance
with hospital policy on patient referral
All inpatients have an initial assessment(s) Yes Yes Yes Yes Yes Yes Yes Yes
which includes an evaluation of physical,
psychological, social, and economic factors
and all assessment must be documented
legibly
The entries in the medical record must Yes: 32 Yes: 30 Yes: 32 Yes: 34 Yes: 32 Yes: 34 Yes: 36 Yes: 34
contain numeric date (D/M/Y) No: 8 No: 10 No: 8 No: 6 No: 8 No: 6 No: 4 No: 6
• Numeric time
• Name with stamp
• Appropriate initials of care provider
(Graph 4)
Patient care record must be maintained/kept Yes: 34 Yes: 36 Yes: 36 Yes: 34 Yes: 32 Yes: 32 Yes: 34 Yes: 34
in their individual folders (Graph 5) No: 6 No: 4 No: 4 No: 6 No: 8 No: 8 No: 6 No: 6
Alteration or correction in the medical record Yes: 32 Yes: 32 Yes: 34 Yes: 34 Yes: 32 Yes: 32 Yes: 38 Yes: 34
must remain legible by using a single line No: 8 No: 8 No: 6 No: 6 No: 8 No: 8 No: 2 No: 6
to score out the information to be corrected
(Graph 6)
Medical records must not include Yes Yes Yes Yes Yes Yes Yes Yes
abbreviations other than those approved,
published, and made available to all staff
All the discharge summary contains details of Yes: 34 Yes: 32 Yes: 34 Yes: 36 Yes: 32 Yes: 32 Yes: 36 Yes: 34
No: 8 No: 10 No: 8 No: 6 No: 8 No: 8 No: 4 No: 6
• Summary of diseases
• Treatment given
• Follow-up instruction
• Instruction for patients (Graph 7)
Discharge summary contains ICD number Yes: 36 Yes: 34 Yes: 34 Yes: 36 Yes: 36 Yes: 38 Yes: 32 Yes: 38
(Graph 8) No: 4 No: 16 No: 6 No: 4 No: 4 No: 2 No: 8 No: 2
Discharge summary contains signature of Yes Yes Yes Yes Yes Yes Yes Yes
treating physician/surgeon
MLC initiated in all cases where it should be Yes Yes Yes Yes Yes Yes Yes Yes
initiated
LAMA patients have given their unwillingness Yes Yes Yes Yes Yes Yes Yes Yes
of treatment (Graph 9) No: 2 No: 4
Lab investigation form duly filled and entered Yes: 38 Yes: 32 Yes: 36 Yes: 36 Yes: 34 Yes: 38 Yes: 34 Yes: 38
in case sheet (Graph 10) No: 2 No: 8 No: 4 No: 4 No: 6 No: 2 No: 4 No: 1
ICD: International classification of diseases; MLC: Medicolegal case; LAMA: Leaving against medical advice

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Medical Audit of Documentation of Inpatient Medical Record in a Multispecialty Hospital in

RECOMMENDATIONS
• Sensitizing the clinical and clerical staff regarding
• Root cause analysis to be done to find out the reason the importance of correct record keeping should be
for lapse in certain departments. stressed to the interns both from a patient care and
research perspective.6
• Hospital-wide standardization of the medical
record keeping including admission and discharge
summary.7
• 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 hospital.
• There should be quarterly medical audit of the
docu- mentation procedure.
• The interns/residents responsible for filling in the
inpatient records should be taught how to
adequately fill in the records in a scientific manner.8
• A weekly check of the medical records by consultant
to assure that it is being completed.
Graph 1: Planned care not provided to patient as per • In addition, sections in the pro forma should be filled
standard protocol
in according to their title, to maintain clarity of notes.9

Graph 2: Updated or revised plan, as appropriate, based on the reassessment of the patient by the care providers

Graph 3: Nondocumentation of food order in medical record Graph 4: Entry in medical record for date/name/sign

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Madhav M Singh et

Graph 5: Patient care record not maintained/kept in their Graph 6: Alteration or correction in the medical record
individual folders

Graph 7: Completion of discharge summary Graph 8: International Classification of Diseases number not
entered in discharge summary

Graph 9: Leaving against medical advice patients have not respective physician.10
given their unwillingness of treatment

• It should be the responsibility of the discharging

doctor or ward in charge to return to the inpatient
records and complete the required section on
“follow-up”. This should also be signed by the

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Medical Audit of Documentation of Inpatient Medical Record in a Multispecialty Hospital in

Graph 10: Lab investigation form duly filled and entered
in case sheet

CONCLUSION
Medical records are technically valid health records
which must provide an overall correct description of
each patient’s details of care or contact with hospital
personnel.

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 Madhav M Singh et
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