Abstract:

 

Introduction: Healthcare audit is a retrospective evaluation of work done by healthcare professionals which is documented in the healthcare records of patients. It helps to understand lacunae in healthcare practice. Many a times, one observes errors and gaps in documentation. Such evaluation helps to plan solutions to these issues, to provide best possible quality care to our patients.

Aim of the study was to assess compliance levels of in-patient healthcare records with healthcare audit in a selected teaching hospital in Pune city, India.

 

Methodology: Explorative and retrospective quantitative survey was carried out on 150 inpatient medical records which were randomly selected. Three point likert scales was used i.e.  0= non compliance, 1= partial compliance, and 2= full compliance.

 

Results: Audit tool consisted 52 items under six headings such as history and physical examination, nursing assessment, medication administration, daily nursing “Flow sheet”, progress note and consent form. This study shows that in-patient healthcare records were not up-to the standard and has number of lacunae; hence need serious attempts towards improvement. Majority of items show no compliance hence needs extra efforts on education and training of healthcare professionals. Mainly, it shows need for improvement in current practices of documentation.

 

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