@article{Mehmood_Shakeel_Saeedi_Din_2011, title={AUDIT OF MEDICAL RECORD DOCUMENTATION OF PATIENTS ADMITTED TO A MEDICAL UNIT IN A TEACHING HOSPITAL NWFP PAKISTAN}, volume={21}, url={https://www.jpmi.org.pk/index.php/jpmi/article/view/8}, abstractNote={<span style="font-family: Times New Roman; color: #1f1a17; font-size: x-small;"><span style="font-family: Times New Roman; color: #1f1a17; font-size: x-small;"><span style="font-family: Times New Roman; color: #1f1a17; font-size: x-small;"><p>Objective: To audit the medical record documentation of patients admitted to a medical unit in year 2005</p><p>at a teaching hospital NWFP Pakistan.</p><p>Material and Methods: The retrospective audit was conducted in the Medical "C" Unit of Government</p><p>Lady Reading Hospital Peshawar from 1st January 2005 to 31st December 2005. Out of 3944 patients</p><p>admitted during 2005, 200 case notes were randomly selected and subjected to audit. The clinical notes</p><p>were broadly analysed for documentation of six parameters. Each parameter’s documentation was to be</p><p>graded as very good, good, average, poor, or not documented.</p><p>Results: Personal bio-data was documented good in 194(97%) cases; history and examination were good</p><p>in 22 (11%) cases; diagnosis was very good in 48 (24%) cases; Investigation were documented very good</p><p>in 18 (9%) cases and good in 134 (67%) cases; Progress notes were good in 156 (78%) cases and</p><p>treatment was documented good in 186 (93%) cases. In 82 (41%) charts, one or more of the six selected</p><p>items were not documented at all. Investigations were not written in 20%, progress notes in 12%, history</p><p>and examination in 9%, diagnosis in 6%, treatment in 3% and bio-data in 1% of the case notes</p><p>Conclusion: Documentation of important clinical information is poor even in the hospital charts of</p><p>patients admitted in tertiary care hospital. Poor documentation in medical records might reduce the quality</p><p>of care and undermine analyses based on retrospective chart reviews.</p></span></span></span>}, number={2}, journal={Journal of Postgraduate Medical Institute}, author={Mehmood, Khalid and Shakeel, Shahid and Saeedi, Ilyas and Din, Zia ud}, year={2011}, month={Jul.} }