Process audit on quality of out-patient records using WHO chart audit as a tool for training interns and improving quality of service delivery in an urban health training centre
Journal Title: Journal of Education Technology in Health Sciences - Year 2018, Vol 5, Issue 1
Abstract
Patient care documentation is an important component of health care service delivery and continuity of care within the health system Case documentation audit is a good tool to improve the quality of service and to help train budding doctors about the expected standard of care This study was done as part of a Competent Interns training program for primary care as well as a quality improvement program to improve patient care documentation in an Urban health training center The specific objectives were to identify the gaps in practice and serve as the baseline quality of Outpatient case records and using the gaps in practice to conduct an educational intervention among Interns The effectiveness of this intervention was then measured by noting the changes seen upon reauditMaterials and Methods1nbspnbspnbspnbspStudy design Intervention study Educational following a process audit2nbspnbspnbspnbspStudy sample All new Outpatient case records from November 2014 to January 2015 for baseline study and new Outpatient case records from April to June 2015 for reaudit after setting targets3nbspnbspnbspnbspSetting Primary health care training center catering to an urban area4nbspnbspAnalysis Results are expressed in percentage of records with adequate documentation for each items in the checklist Overall mean score plusmn standard deviation for records were calculated pre and post audit separately and t test was done to detect for statistically significance 1 level of significance following the educational interventionResults Baseline audit n110 showed 100 97 and 95 records had documented patients details patient complaints and physical examination on case sheets respectively There was poor documentation of drug allergies 1 review date 36 and name of the examining doctor or intern 3Following the educational intervention during the reaudit n75 there was overall improvement in case sheet recording practice t1534 plt0001 among the health care staffConclusions Identification of gaps in documentation practice using a validated standard of care audit tool helps Training Interns got to learn this useful managerial skill so that they are trained for quality improvement at Primary Care levelKeywords Case sheets audit Competent Interns Gap identificationnbsp
Authors and Affiliations
Prabha Thangaraj, Thomas V. Chacko
Keywords
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- EP ID EP488162
- DOI 10.18231/2393-8005.2018.0004
- Views 22
- Downloads 0
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