Documentation of Inpatient Medical Records: A Clinical Audit

Figures & data

Figure 1 RCP Personal data and History section.

Figure 2 RCP the rest of the History section and Clinical examination section.

Figure 3 RCP Investigation and Management plan sections.

Figure 4 RCP Diagnosis and Progress Notes section.

Figure 5 RCP Admission & Discharge section.

Figure 6 RCP Attending doctors and legibility of notes section.

Table 1 Standard Criteria and Assessment Parameter Application

Assessment Parameter	1st Cycle	2nd Cycle
1. Personal Data	Done	Done
Name	100%	100%
Age	80.4%	100%
Gender	74.1%	100%
Occupation	16.1%	74%
Weight	12.5%	37%
Address	66.1%	94%
ID Number	83.8%	89%
Contact Number	14.3%	76%
2. History Section 1st Part	Done	Done
Presenting Complain	64.3%	100%
History of Presenting Complain	41.2%	100%
Systemic Review	37.5%	98.1%
Past Medical	71.4%	98.1%
Medication	69.7%	96.3%
Family	41.1%	85.2%
3. History Section 2nd Part	Good	Good
Social history habits (smoking, alcohol…)	10.7%	81.5%
Social history (impact of the disease)	0%	64.8%
Psychiatric	5.4%	29.6%
Sexual	1.8%	40.7%
Obstetric & Gynecological	17.9%	70.4%
Dietary	3.6%	53.7%
Travel	1.8%	35.2%
4. Clinical Examination	Done	Done
Vitals	55.4%	100%
Focus Examination	53.6%	98.1%
Other Systems examination	32.1%	100%
5. Investigations	Done	Done
Required tests	66.1%	96.3%
Tests Results	66.1%	100%
Flow Chart of Results	10.7%	96.3%
6. Admission & Discharge	Done	Done
Admission Date	83.9%	100%
Discharge Type	39.3%	87%
Discharge Note	1.8%	44.4%
7. Diagnosis	Done	Done
Admission summary	21.4%	85.2%
Provisional diagnosis	44.6%	81.5%
Problem list	8.9%	50%
Final diagnosis	64.3%	100%
8. Management Plan	Good	Good
Medication Prescription	73.2%	94.4%
Interventions & procedures	42.9%	98.1%
Follow up instructions	33.9%	92.6%
Patient instructions	14.3%	70.4%
9. Legibility of Notes	Yes	Yes
The Notes are Legible	44.6%	85.2%
Attending Doctors details are written	12.5%	70.4%

Table 2 Overall Impression

Overall Impression	1st Cycle	2nd Cycle
Excellent	0%	55.6%
Good	33.3%	44.4%
Poor	55.6%	0%
Non- Satisfactory	11.1%	0%