Gupta Anant, Jain Kanika, Bhoi Sanjeev
Department of Hospital Administration, All India Institute of Medical Science, New Delhi, India.
Department of Hospital Administration Super Specialty Cancer Institute and Hospital, Lucknow, Uttar Pradesh, India.
J Emerg Trauma Shock. 2020 Oct-Dec;13(4):257-263. doi: 10.4103/JETS.JETS_88_18. Epub 2020 Dec 7.
A medical record audit is a type of quality assurance task which involves formal reviews and assessments of medical records to identify where a medical organization stands in relation to compliance and standards. A study was carried out with the objective to document the audit of the medical records in a tertiary care trauma center and suggest the corrective measures and preventive measures in case of lacunae.
A retrospective study was conducted in an apex trauma care facility of New Delhi. All the admissions on disaster bed from October 1, 2015, to December 31, 2015, were evaluated. A list of 106 admissions were made using the online software at the trauma center. The files were taken from the medical record departments and compared using a checklist prepared in accordance with the guidelines laid down by the Joint Commission International.
A total of 106 admissions on disaster bed from October 1, 2015, to December 31, 2015, were evaluated. The average length of stay for the disaster beds was 11.7 days and the mortality rate was 9.5%. Signature of the patient and doctor and name of the witness were missing in more than 50% of the cases of consent. Discharge summary in which the investigation details, signature of the doctor, and contact number in case of an emergency were not documented. In the miscellaneous records, transfer (61%) and referral (42%) were not documented properly.
The average length of stay for the disaster beds was 11.7 days. Maximum admissions were under the neurosurgery department. The filing and assembling of records were poor. Signature of the patient and doctor and name of the witness were missing in more than 50% of the consent forms. There was no anesthesia consent form used. The doctor daily records were poor, while the nursing records were well maintained. It is recommended to have a periodic weekly auditing to minimize chances of deficiency/misplacing of records. Periodic training sessions and workshops should be organized.
病历审核是一种质量保证任务，涉及对病历进行正式审查和评估，以确定医疗组织在合规性和标准方面的状况。开展了一项研究，目的是记录一家三级创伤护理中心的病历审核情况，并针对不足之处提出纠正措施和预防措施。
在新德里的一家顶级创伤护理机构进行了一项回顾性研究。对2015年10月1日至2015年12月31日期间所有在灾难病床的入院病例进行了评估。使用创伤中心的在线软件列出了106例入院病例清单。从病历部门获取文件，并使用根据国际联合委员会制定的指南编制的检查表进行比较。
对2015年10月1日至2015年12月31日期间在灾难病床的106例入院病例进行了评估。灾难病床的平均住院时间为11.7天，死亡率为9.5%。超过50%的同意书病例中缺少患者和医生的签名以及证人姓名。出院小结中未记录检查细节、医生签名和紧急情况下的联系电话。在杂项记录中，转诊（61%）和转介（42%）记录不完整。
灾难病床的平均住院时间为11.7天。神经外科的入院病例最多。病历的归档和整理情况较差。超过50%的同意书中缺少患者和医生的签名以及证人姓名。未使用麻醉同意书。医生的日常记录较差，而护理记录保存良好。建议每周进行定期审核，以尽量减少病历缺失/错放的可能性。应组织定期培训课程和研讨会。
