Analysis of Health Record Documentation Process as Per the National Standards of Accreditation with Special Emphasis on Tertiary Care Hospital
Journal Title: International Journal of Health Sciences and Research - Year 2017, Vol 7, Issue 6
Abstract
The study entitled “Analysis of Health Record Documentation Process As Per The National Standards Of Accreditation with special emphasis on Tertiary Care Hospital” aims to review the health records and evaluate them to find the incongruity in the documentation of patient’s data by doctors, nurses and other healthcare providers involved in the documentation process. Health records form an imperative part of management of a patient. It is important for the doctor, nurses and medical establishments to properly maintain the records of patient’s for two significant reasons. The first reason is that it will help them in the scientific evaluation of patient profile, to analyze the treatment results, and to plan appropriate treatment protocols. The other reason is that it will assist in planning governmental strategies for future medical care. The study was conducted in X Hospital in Delhi. A total of 200 patients files reviewed and primary data collected by checking the patient files at nursing stations, wards and critical areas. A documentation review audit tool was then prepared (as per objective elements mentioned by NABH) taking into consideration the important aspects of documentation in the health records. The files were checked as per the parameters mentioned in the audit tool. To measure the compliance, three options were included i.e. Full compliance, Partial compliance and Non compliance. Then the percentage (%) compliance was calculated for each health record form. Data interpretation and analysis was done and major non-compliances were reported to the doctors, nurses and paramedical staff along with reasons for their non-conformity with the NABH standards. Possible suggestions and recommendations were also reported. This helped in bringing down the percentage of non-compliance.
Authors and Affiliations
Prerna Singh
Keywords
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