Abstract
The primary purpose of medical records is to support patient care. It is a means of communication and secondarily, it is an important medicolegal document. Current standards of clinical records are variable. The aim of this study was to assess the adequacy of case notes in a tertiary care hospital and compare it with that of world standards. 231 case records of inpatients in the general surgery department who were discharged were audited retrospectively. Out of 53 standards analyzed, 7 had 100% compliance. More than 75% of compliance was achieved in 30/53 standards. A significant lapse in record keeping was found in daily entries by doctors, the timing of entries, details of initial assessment, and daily progress notes. Maintaining high-quality clinical record is an important part of our responsibility. Deficiencies show up in formal audits of case records. Regular orientation programs to improve the quality of clinical records and regular auditing of case notes are required to ensure adequacy.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
Data Availability
All data analyzed during this study are included in this article
Code Availability
No code or program used
References
Baird, B. (2013). Internship, practicum, and field placement handbook. New York: Routledge Available via https://doi.org/10.4324/9781315663890. Accessed 28 Apr 2014
Mann R, Williams J (2003) Standards in medical record keeping. Clin Med 3(4):329–332
Joint Commission International (2013). Joint Commission International accreditation standards for hospitals. 5th Edition. Available via.https://www.kfshrc.edu.sa/store/media/1oh.pdf. Accessed 23 Aug 2014
Guidelines for progress notes. (2008). Available via http://www.columbia.edu/itc/hs/medical/medicine. Accessed 28 Apr 2014
Guidelines for clinicians on medical records and notes. Royal College of Surgeons of England. (1990), AMRO, 31(3): 18–20
World Health Organization. Regional Office for the Western Pacific. (2003). Improving data quality: a guide for developing countries. Manila : WHO Regional Office for the Western Pacific Available via https://apps.who.int/iris/handle/10665/206974. Accessed 23 May 2014
Chamisa I, Zulu BMW (2007) Setting the records straight-a prospective audit of the quality of case notes in a surgical department. S AfrJ Surg 45(3):92–94
Adeleke IT, Adekanye AO, Onawola KA, Okuku AG, Adefemi SA, Erinle SA, Shehu ARA, Yahaya OE, Adebisi ALA, James JA, AbdulGhaney OO, Ogundiran LM, Jibril AD, Atakere ME, Achinbee M, Abodunrin OA, Hassan MW (2012) Data quality assessment in healthcare: a 365-day chart review of inpatients’ health records at a Nigerian tertiary hospital. J Am Med Inform Assoc:JAMIA 19(6):1039–1042
Osborn G, Pike H, Smith M, Winter R, Vaughan-Williams E (2005) Quality of clinical case note entries: how good are we at achieving set standards? Ann R Coll Surg Engl 87:458–460. https://doi.org/10.1308/003588405X60632
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical Approval
This was an audit. No experimental work was carried out. Patient records were perused . They were not directly involved in any manner. Confidentiality is maintained—hence, no ethical committee approval is needed.
Additional information
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Divya T K, Lakshman K Adequacy of Case Notes in a Tertiary Care Hospital—an Audit. Indian J Surg 83, 43–47 (2021). https://doi.org/10.1007/s12262-020-02269-w
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12262-020-02269-w