Out-patient Record Audit in Srinagarind Hospital

Abstract

Abstract

Background: Medical record has many useful appliances such as, continuing medical care, medical learning, research, hospital management and legal evidence.  Until now, there have had a few medical record audit researches in Thailand.  We audit the out-patient record in Srinagarind hospital aiming to be the baseline data and pilot study for our own medical record audit form.

Purpose: To report the result of out-patient record audit in Srinagarind hospital.

Patients and Methods: In the first three month of 2005, out-patient records (750) were selected by cluster sampling from 10 department of Srinagarind hospital.  All of these records were audit by our own medical record audit form in 12 items.  The result of audit were recorded and reported in means score.

Study design: Descriptive study

Setting: Srinagarind Hospital, Khon Kaen, Thailand

Results: The overall quality of out-patient record in Srinagarind hospital was fair (62.45%).  The parts of medical record which was done by doctor had a fair rank and lower than the part which was done by non-doctor, nurse and medical record officer.  Four of seven items of doctor’s part had a fair rank and two had under standard rank, the records about plan of treatment and drug allergy.

Discussion and Conclusion: In Srinagarind hospital which separated into many departments, there were the different in patient types and demand of each department for their service. These result in variation in out-patient record of the hospital.  Every hospital should define the standard medical record form to all departments.  The director of the hospital should stimulated the relevant person who take part in medical record especially doctor about the most common error for the improvement of medical record quality and prompt to qualified by every institutes.

Key words: audit; medical record; form