Study of Medical Records Department at a tertiary care teaching hospital with special reference to Medical Audit

Dr Arun Kanth Madri; Dr J.N.Rao; Dr Rama mohan Desu; Dr Sasikala

Volume : VIII, Issue : VI, June - 2019

Study of Medical Records Department at a tertiary care teaching hospital with special reference to Medical Audit

Dr Arun Kanth Madri, Dr J. N. Rao, Dr Rama Mohan Desu, Dr Sasikala

Abstract :

INTRODUCTION: Medical record is a clinical, scientific, administrative and legal document to justify diagnosis and treatment. Medical audit is a professional evaluation of quality care. The aim was to study physical facilities, staffing, workflow, deficiency check and medical audit METHODS: Prospective observational study of facilities, staffing and work flow Retrospective study of case sheets for deficiency check and medical audit . RESULTS AND DISCUSSION: Area available is 278 m2 which is inadequate against norm of 350 m2. Existing staff of 28 is adequate as per norms. Deficiencies were observed in physical examination (44%), history (43%), radiology (40%), anesthesia (28%) and laboratory reports (16%).CONCLUSION AND RECOMMENDATIONS: Staff & Equipment was adequate. Recommended for regular staff training and usage of Electronic medical records, Focus on deficiency check by specific MRD staff on regular basis monitored by the administration and supported by medical audit committee