Authors : Prabha Thangaraj, Thomas V. Chacko
DOI : 10.18231/2393-8005.2018.0004
Volume : 5
Issue : 1
Year : 0
Page No : 15-19
Patient care documentation is an important component of health care service delivery and continuity of care within the health system. Case documentation audit is a good tool to improve the quality of service and to help train budding doctors about the expected standard of care. This study was done as part of a Competent Interns training program for primary care as well as a quality improvement program to improve patient care documentation in an Urban health training center. The specific objectives were to identify the gaps in practice and serve as the baseline quality of Out-patient case records and using the gaps in practice to conduct an educational intervention among Interns. The effectiveness of this intervention was then measured by noting the changes seen upon re-audit.
Materials and Methods:
<!--[if !supportLists]-->1. Study design: Intervention study (Educational) following a process audit
2. Study sample: All new Out-patient case records from November 2014 to January 2015 for baseline study and new Out-patient case records from April to June 2015 for re-audit after setting targets
<!--[if !supportLists]-->3. Setting: Primary health care training center catering to an urban area.
4. Analysis: Results are expressed in percentage of records with adequate documentation for each items in the checklist. Overall mean score ± standard deviation for records were calculated (pre and post audit separately) and t test was done to detect for statistically significance (1% level of significance) following the educational intervention.
Results: Baseline audit (n=110) showed 100%, 97% and 95% records had documented patients details, patient complaints and physical examination on case sheets respectively. There was poor documentation of drug allergies (1%), review date (36%) and name of the examining doctor or intern (3%).Following the educational intervention during the re-audit (n=75) there was overall improvement in case sheet recording practice (t=15.34; p<0.001) among the health care staff.
Conclusions: Identification of gaps in documentation practice using a validated standard of care audit tool helps. Training Interns got to learn this useful managerial skill so that they are trained for quality improvement at Primary Care level.
Keywords: Case sheets audit, Competent Interns, Gap identification.