AIM: With the background knowledge that auditing of Medical Records (MR) for adequacy and completeness is necessary if it is to be useful and reliable in continuing patient care; protection of the legal interest of the patient, physicians, and the Hospital; and meeting requirements for researches, we scrutinized theatre records of our hospital to identify routine omissions or deficiencies, and correctable errors in our MR system.
METHOD: Obstetrics and Gynaecological post operation theatre records between January 2006 and December 2008 were quantitatively and qualitatively analyzed for details that included: hospital number; Patients age; diagnosis; surgery performed; types and modes of anesthesia; date of surgery; patients’ ward; Anesthetists names; surgeons and attending nurses names, and abbreviations used with SPSS 15.0 for Windows.
RESULTS: Hardly were any of the 1270 surgeries during the study period documented without an omission or an abbreviation. Hospital numbers and patients’ age were not documented in 21.8% (n=277) and 59.1% (n=750) respectively. Diagnoses and surgeries were recorded with varying abbreviations in about 96% of instances. Surgical team names were mostly abbreviated or initials only given.
CONCLUSION: To improve the quality of Paper-based Medical Record, regular auditing, training and good orientation of medical personnel for good record practices, and discouraging large volume record book to reduce paper damages and sheet loss from handling are necessary else what we record toady may neither be useful nor available tomorrow.
Medical Record, Electronic Record, Paper-Based Record, Medico-Legal