ROLLING AUDIT: DEFENSIBLE RECORD KEEPING

Abstract

Objectives:

To observe the completeness and proper documentation of inpatients data, to compare the observed data of present rolling audit to previous rolling audit and also to observe implementation of recommendation made by previous rolling audit.

Material and Methods:

Retrospective study done on November 2009.  Twenty files from each of eight departments having inpatient ward at TU teaching hospital was analyzed. Files were reviewed for completeness and proper documentation as per protocol laid down by Royal College of Surgeons.

Results:

Record keeping was appreciable in department of Pediatrics, Psychiatric and ENT-HNS. There was deteriorating trend of data recorded in admission and investigation form. Progress notes were properly filled daily in department of Medicine, Surgery, Pediatrics, ENT-HNS and Gynecology and Obstetrics. There was no significant implementation of recommendation of previous rolling audit in all the departments.

Conclusion:

Good medical practice is defensible practice. Rolling audit must be done at regular basis to implement change and further monitoring to confirm improvement.

Keywords: audit, data, record keeping