Clinical Audit of Medical Records -A Case Study in Tertiary Care Hospital of Goa, India (2014)

Asian Resonance(P: ISSN No. 0976-8602 RNI No. UPENG/2012/42622 VOL.-III, ISSUE-III, JULY-2014 E: ISSN No. 2349-9443) 

Abstract

 Ajai Kumar Jain

 Assistant Professor, Institute of Management Studies, Devi Ahilya University, Indore.

Santosh Kumar Choube 

Assistant Professor, Institute of Management Studies, Devi Ahilya University, Indore.


Hrishiraj Panwar

 Hospital Administrator at Wockhardt Hospital, Goa.

Quality and cost are two important issues in medical care. Clinical audits are the tools for improving quality in healthcare provided by hospitals. Clinical audit is the post mortem (depends on historical records) of clinical inputs and outputs to evaluate the quality of medical care by physicians and healthcare personnel in the hospital. Involvement of clinical staff is crucial for this quality effort. This study focuses on Clinical audit in a tertiary care hospital. The study checks the compilation of manual records on paper as well as electronic records in Hospital Information System (HIS) by the clinicians. The study was conducted in six departments of a tertiary care hospital for the duration of four months. It was observed that in few areas of Medical records, Clinicians are not filling the required details. These records help the patient and clinician to cross check the course of treatment underwent by the patient during their stay in the hospital. The study concluded that Orthopaedics department had maximum compliance and dental had the minimum compliance among the six departments. Recommendations include the instructions and training to medical staff periodically to reduce such gaps discovered in clinical audit to improve the quality of medical care and also to reduce litigations by the patients.  

for full paper please visit below link :

http://www.socialresearchfoundation.com/upoadreserchpapers/1/15/14110612380033%20ajay%20kumar%20jain.pdf

 


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