Abstract : Medical records play a pivotal role in enabling healthcare professionals to plan and evaluate patient treatments, ensuring a seamless continuum of care across different providers. The precision and lucidity of information in the medical record directly influence the quality of care delivered to a patient. Maintaining comprehensive records is crucial not only to meet requirements for certification and licencing, but also to allow medical professionals to verify that patients have received the right treatment. Clinical audit is a technique that is used in quality improvement to evaluate services against predetermined criteria and facilitate required modifications in order to improve patient outcomes.. Two retrospective assessments of medical record quality were carried out using a random sampling strategy and a 48-item evaluation grid across 9 domains. The evaluation showed a significant improvement in all sections of the medical chart during the second analysis compared to the first. After an initial assessment of 1,460 medical records, a departmental audit program was established. The second evaluation, following internal auditing, was conducted on 1,402 medical records, revealing an increase in all scores above 50% [1].
Keywords :
Cite : Chandel, R., & Das, A. (2023). Audit Of Documentation Of Medical Records As Per Nabh Standards (1st ed., p. 67). Noble Science Press. https://doi.org/10.52458/9789388996990.2023.eb.ch-17
References :
Poscia, A., Azzolini, E., Cacciatore, P., De Belvis, A. G., Volpe, M., Cambieri, A., ... & Specchia, M. L. (2018). Does Clinical Governance influence the quality of medical records?. Annali dell'Istituto Superiore di Sanità, 54(2), 104-108.
Gabbay, J., & Layton, A. J. (1992). Evaluation of audit of medical inpatient records in a district general hospital. BMJ Quality & Safety, 1(1), 43-47.
Singh, P., & John, S. (2017). Analysis of health record documentation process as per the national standards of accreditation with special emphasis on tertiary care hospital. Int J Health Sci Res, 7(6), 286-292.
