Abstract
Clinical audits enable a more responsible and patient-centric healthcare paradigm by comparing patient care processes to self-defined standard norms. The current study is a descriptive prospective observational analysis performed on data extracted from in-patient active audit files from a multispecialty hospital based in Delhi NCR, India. The files were reviewed to find out if the current documentation technique adhered to the accreditation board's audit guidelines.
A random sample of 325 files among all inpatient medical records from the selected wards of the hospital was analyzed in accordance with standard protocols. The information gathered was primary in nature with 15-20 files being audited from different wards daily based on fulfillment of National Accreditation Board of Hospitals (NABH) criterion.
Active audit data collection was lacking in many criteria like desired outcomes (25.2%) and others. Educating clinical staff about the necessity of accurate form recording and hospital-wide consistency of medical record keeping, providing summary of admission and discharge is vital. Utmost care should have been taken to ensure that hospital medical records are maintained in a systemic and scientific manner.
There is an acute need for proper documentation to improve the quality. Active audits of this nature should be made regular to improve the standard of care over time.