Keywords :
Assessment, Medical Records, Joint Commission International.

ABSTRACT

Objective : To evaluate the medical documentation process compared to criterion as per Joint Commission International.

Method : A retrospective study was conducted in a cancer hospital of Karnataka, India, for a period of 4 months. A total of 600 discharged inpatient records were randomly selected from the records of total patients admitted and discharged during the year 2008. A checklist was then prepared as per the medical documentation criterion laid down by JCI. To measure the compliance three options were included i.e. “Yes”, “No” and “Not Applicable”. The forms considered for the assessment were Admission form, Consent form, Radiation form, Brachytherapy form, Anesthesia consent and management form, Post operative form, Doctor’s record, Nurses record and Discharge Summary.

Results : A total of 49% non compliance was seen in General consent in respect to the signature of doctors with date, whereas, 18% of anesthesia forms failed to provide any evidence of anesthesia used during the surgery. It was found that the standard documentation of the discharge summary was most dissatisfactory, where 44% of discharge summary does not comply with criteria of JCI.

Conclusion : Though overall medical documentation process was satisfactory, the documentation of General consent form and Anesthesia form needs to be enhanced further as per the standards framed by the Joint Commission International. Special attention should be given to the complete and accurate documentation of Discharge summary.