Comparative Study of Errors of Documentation by Junior Residents in Medical Records of Patients, Who Died in Medical Intensive Care Unit of 1000 Bedded Teaching Hospital in Year 2014-2015
Journal Title: Journal of Medical Science And clinical Research - Year 2016, Vol 4, Issue 4
Abstract
Aims and Objectives: To study errors of documentation by junior residents (JRs) and to compare error rates of year 2014 with year 2015. Methodology: This study was interventional, record based, prospective, cross sectional study, with duration of two year from January 2014 to December 2015. After obtaining approval from Institutional Ethics Committee, a total of 222 death file of year 2014 and 240 death files of year 2015 of Medical intensive care unit(MICU) were obtained from Medical Record Department(MRD) of Lata Mangeshkar Hospital, Hingna, Nagpur. In the year 2015 regular monthly death audit meetings were conducted to overcome fallacies noticed in 2014. Data obtained was analyzed by chi square test. Results: Statistically significant improvement was seen in parameters like daily revised treatment notes, name of Dead body (DB) and death Certificate (DC) receiver, procedure notes, Relation of DB and DC receiver with deceased, time of DB & DC handing over, daily progress notes, date of DB & DC handing over, senior review of USG/CT/MRI and signature of senior resident/lecturer on death summary. Discussion: Error rates were reduced in 2015 as compared to 2014, which is attributed to detailed discussion of errors and proper training of JR’s in medical record keeping. Conclusion: Meticulous record keeping is needed to avoid observations from various agencies like consumer forum, insurance agencies and government health authorities and to improve health care provision in general. It is possible with proper training of junior residents.
Authors and Affiliations
Vivek K. Pande
Keywords
Related Articles
- EP ID EP209441
- DOI -
- Views 55
- Downloads 0
PERCEIVED CAUSES OF DOMESTIC VIOLENCE IN MARRIED WOMEN WITH MENTAL ILLNESS & PHYSICAL ILLNESS
Background: Domestic violence against women is the most pervasive human rights violation in the world today. Violation not only causes physical injury, it also undermines the social, economic, psychological, spiritual an...
Study on Awareness of Diarrheal Disease Control Among Health Personnel and Mothers
Background: Diarrhea remains a leading killer of young children, despite the availability of simple treatment solution. It accounts for 9% of all deaths among children under 5 years of age worldwide. Information on diarr...
Evaluation of efficacy of gastrografin in adhesive small bowel obstruction
Background: Various conservative means of managing ASBO have been reported, including nasogastric tube suction and fluid resuscitation, and administration of water-soluble contrast agents, such as gastrografin, which may...
Radiological Response Assessment in High Grade Gliomas: 3DCRT vs IMRT
Objectives: To compare the radiological response in high grade glioma patients receiving post-operative radiation therapy via 3DCRT /IMRT technique with concurrent and adjuvant temozolomide. Materials and Methods: Twenty...
Comparison of Two Brands of LASIK Work Stations in Achieving the Best Desired Therapeutic Result in LASIK Surgery – A Retrospective Study
Aim of this study is to compare the effectiveness of the two leading brands of the LASIK (Laser in situ Keratomileusis) work stations in treating the refractive status of the patients selected for the study, and to know...