Retrospective audit in documentation practice in surgical inpatients records, a two cycles audit

Abstract

Background

To provide safe and effective patient care, records must be kept in a high-quality manner. Clinical audits should be conducted on a frequent basis to ensure that high standards of record-keeping are upheld. An audit and re-audit of the surgical inpatient records’ documentation were conducted as part of a retrospective, descriptive study to see if it aligns with the hospital’s stated policy.

Aims/objectives

Evaluating the hospital’s present documentation process and considering how current practice could be improved were the key objectives of the audit project.

Method

An interactive form was created to audit the criteria using standard hospital guidelines as a foundation. Retrospective analysis of 120 case files served as the main source for the information gathered. The documentation in the records was evaluated to determine whether it was accurate and complete in every section. The data was collected, analyzed, and presented at clinical governance. These outcomes were implemented in our documentation protocol in a way that all surgical personnel are given instructions on the appropriate documentation and how to complete it. This data was again, prospectively collected to complete the audit cycle.

Results

Thirty-five of the 37 relevant audit standards witnessed an increase in compliance. No standard or criterion’s compliance dropped during the re-audit cycle. Since the first audit cycle, compliance has increased on average by 32% across all audit criteria, suggesting that some of the work done after the first cycle has had a significant effect.

Discussion/conclusions

Record-keeping must be considered as an integral part of medical practice; current documentation work demonstrates that when performed appropriately, audit can actually affect the quality of clinical records. The audit itself can increase awareness of the need for practice improvement. The distribution of findings, instruction, training, and local action planning are all essential for developing practice.