Need for Improvement of Medical Records

Abstract

Introduction: A medical record is a systematic documentation of a patient’s medical history and care for legal and future use. A poor quality medical record can negatively affect patient care and safety. The study aims to assess the adequacy of medical records in Bir Hospital, a central hospital.Methods:A cross-sectional study was conducted by analyzing consecutive discharge summaries of patients admitted during a 6 month period in a single unit of a tertiary care center. The discharge summary format of the hospital was taken as the standard and evaluation for adequacy of data entered was assessed. Descriptive statistics were used to analyze various statistical discrepancies. Results: Patient’s condition at discharge was missing in 86 (66.15%). Patient’s address was missing in 21 (16.1%) cases. Almost all the discharge sheets lacked mailing address. Total 96 (73.8%) had use of abbreviations diagnosis. Age and sex were missing in 1 (0.76%). Doctor’s signature was illegible in 103 (79.3%) and missing in 2 (1.5%) summaries. Doctor’s name and their level/position were missing in 118 (90.76%) and 125 (96.1%) respectively. Total 126 patients (96.9%) were not given any instructions on discharge.Conclusions: The discharge summaries analyzed were seen to be inadequate especially in documenting course during the hospital stay, condition at discharge, appropriate instructions and the treating physician’s details. These can probably be addressed by introducing electronic medical records if feasible. Otherwise, the discharge summary should be standardized and doctors should be trained to write legible, complete discharge summaries.Key Words: discharge, hospital, records, summaries

Optimizing the quality of hospital discharge summaries – a systematic review and practical tools

“…To improve patient care and safety as well as working conditions for doctors, the current deficits in teaching, discussion and research on this topic must be addressed [13]. Improving the systematic teaching of how to write DS is within the responsibility of the medical schools, specialty training institutions and professional bodies [32,36].…”

“…Despite this effort, DS often have considerable shortcomings regarding their completeness and quality [6,7], which is especially true for the prescription of medications [8]. Studies have consistently shown that, at most, only 70% of the DS meet the requirements established in the guidelines, and up to 40% are incorrect in some way [9][10][11][12][13].…”

The Prevalence and Factors Associated with Prophylactic Antibiotic Use during Delivery: A Hospital-Based Retrospective Study in Palembang, Indonesia

“…Another possible explanation, although less likely, was the possibility of inadequate patient management documentation, including prophylactic antibiotic administration, in the medical record. Despite the significant improvement in medical data recording, inaccurate and incomplete medical records remain a worldwide problem [ 30 , 31 , 32 , 33 ].…”

Impact of a Health Information Technology Intervention on the Follow-up Management of Pulmonary Nodules

“…Access to both discharge instructions and radiology reports would be possible with the discharge module, as opposed to a paper-based discharge summary that a patient is supposed to take to their follow-up ambulatory visit. Discharge summaries are often unavailable or incomplete in many cases [21][22][23][24]. Furthermore, radiology reports are likely to not be included in the printed summaries.…”