Location via proxy:   [ UP ]  
[Report a bug]   [Manage cookies]                
Scribd Logo
Upload

Welcome to Scribd!

  • 128 views

    Medical Audit Format Nicu

    Uploaded by

    nicutkmc2024
    The document outlines the format and documentation requirements for a medical audit. It lists over 20 items that must be documented in patient medical records including the patient's UHID number, diagnosis, treatment plan, lab reports, procedures, medications, and discharge summary contents.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Medical Audit Format Nicu

    Uploaded by

    nicutkmc2024
    128 views2 pages
    The document outlines the format and documentation requirements for a medical audit. It lists over 20 items that must be documented in patient medical records including the patient's UHID number, diagnosis, treatment plan, lab reports, procedures, medications, and discharge summary contents.

    Original Title

    MEDICAL AUDIT FORMAT NICU

    Copyright

    © © All Rights Reserved

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    The document outlines the format and documentation requirements for a medical audit. It lists over 20 items that must be documented in patient medical records including the patient's UHID number, diagnosis, treatment plan, lab reports, procedures, medications, and discharge summary contents.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    128 views2 pages

    Medical Audit Format Nicu

    Uploaded by

    nicutkmc2024
    The document outlines the format and documentation requirements for a medical audit. It lists over 20 items that must be documented in patient medical records including the patient's UHID number, diagnosis, treatment plan, lab reports, procedures, medications, and discharge summary contents.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    MEDICAL AUDIT FORMAT

    Particulars
    UHID number documented

    Documentation of final diagnosis with ICD code on the face sheet

    Discharge / Referral / Death – signed, named, dated and timed by treating


    doctor
    General consent signed by the Medical Officer affixed with name, date and
    time.
    General consent signed by the patient / family / attendant and affixed with
    name, date and time
    TPR chart documented in graphic format indicating of number of in-patient
    days, BP, weight, etc.
    Nutritional screening done by the staff nurse

    Documentation of pain intensity score in VDS in Nursing assessment

    Nursing care plan documented by staff nurse affixed with sign, name, date
    and time
    Medical officer’s name, date and time at the beginning of Initial
    Assessment.
    Provisional diagnosis documented by the treating doctor

    Documentation of treatment plan, goals and objectives by the treating doctor

    Dietary advice documented by the treating doctor


    Medical prescriptions written in a comprehendible manner in uniform
    location, duly signed, by the treating doctor
    Error prone abbreviations used in medical prescriptions

    Informed consents duly signed, named, dated and timed by the patient /
    family / attendant with documentation of relationship to the patient.

    Lab investigations reports provided in a standardized report format duly


    signed, named, dated and timed by the Lab technician and Medical Officer
    i/c of Lab.
    Documentation of date of collection, date of expiry, screening tests results,
    blood group and type in the blood cross matching form duly signed, named
    and dated by the Medical Officer
    Documentation of blood transfusion procedure by treating doctor regarding
    starting time, completion time and post transfusion reaction, if any in the
    patients’ medical records
    Post transfusion reaction form with details documented and duly signed,
    named and dated by the staff nurse and treating doctor.
    Referral notes with signature of the Medical Officer affixed with name, date
    and time.
    Time and signature of staff nurse documented in the medication
    administration chart
    Nurses’ report with signature of the staff nurse affixed with name and date
    Partograph with details signed by the staff nurse affixed with name, date and
    time
    Safe Birth Delivery checklist used for maternal care patients
    Physiotherapy assessment and re-assessment documented, signed, named
    and dated by the physiotherapist affixed with name, date and time
    Patient’s name, UHID number, IP number, age, sex, ward details, hospital
    name and medical record sheet number documented on the continuation
    sheet of the medical record
    Documentation of patient transfer to other hospitals – details of date of
    transfer, reason for transfer and name of the receiving hospital.
    Chronological order of patient care documentation
    Completeness and Legibility
    Discharge summary contents
    a) Patient’s name, age, sex, ward, IP number, UHID number, DOA,
    DOS, DOD documented
    b) ICD codification of final diagnosis, operation and / or procedure
    c) Documentation of investigations done with reports
    d) Documentation of any procedures done (Biopsy, Lumbar Puncture,
    ICD, etc)
    e) Documentation of medications administered during treatment
    f) Condition of patient at the time of discharge
    g) Follow-up advice – Medications to be written in simple format – in an
    understandable manner
    h) Diet advice documented in discharge summary
    i) Information regarding “when” and “how” the patient shall seek urgent
    medical care

    You might also like