Defensible Record Keeping
Abstract
Introduction: Patients records are among the most fundamental of clinical tools and are involved in almost every consultation. It is essential in evaluation the patient’s progress & in a variety of legal contexts including defensive malpractices claims. Way of keeping the records may vary from institute to institute.
Methods: Seven departments having the inpatient were included in the study on November 2013. Thirty files from each department were randomly collected and studied for the complete and proper documentation in (a) admission notes (b) daily progress notes (c) investigation form filling on the basis of inclusion criteria as laid down in the protocol by the Royal College of Surgeons.
Results: Record keeping of the patient’s documents was not satisfactory in all departments. However, entry of date and entry of ward and bed number in an investigations form were filled in all departments.
Methods: Seven departments having the inpatient were included in the study on November 2013. Thirty files from each department were randomly collected and studied for the complete and proper documentation in (a) admission notes (b) daily progress notes (c) investigation form filling on the basis of inclusion criteria as laid down in the protocol by the Royal College of Surgeons.
Results: Record keeping of the patient’s documents was not satisfactory in all departments. However, entry of date and entry of ward and bed number in an investigations form were filled in all departments.