EVALUATION OF MEDICAL RECORD DOCUMENTATION OF A TEACHING HOSPITAL USING NABH CRITERIA

A. Abraham*, S.Saldanha**, GJ Quadiri***, AR Rebello****

 

 

ABSTRACT

The need for appropriate, written documentation of facts related to patients’ treatment in the hospitals cannot be brushed aside, because failure to maintain records means failure of duty towards the patient. To evaluate Medical Records based on the National Accreditation Board of Hospitals (NABH) criteria, a retrospective study was conducted in Medical Records Department of selected teaching hospital in Karnataka. Medical records, belonging to General Surgery Department were included in the study. 450 medical records were randomly selected for this purpose. A checklist was prepared as per the medical documentation criterion laid down by NABH. The forms considered for the assessment were Admission record, Admission order, History sheets, Reference forms, Doctors forms, Consent forms, Pre-operative checklist, Anesthesia record, Operation notes, Nurses record, Medication record, Infection control form, Observation charts, Investigation charts, Hospital service record and Discharge summary. Though overall medical documentation process was satisfactory, Non-compliance was observed with regard to Admission consent(39%),Pre-operative checklist(28%),Drug record (20%) and Intake-Output chart(37%) and Investigation chart for entering requisition time and collection time(55%).

Since Medical records plays an important role in evaluating the quality of care provided, due importance need to be given to Medical Documentation. 

 

Keywords

Medical Records, NABH standards, Documentation