Evaluation of Patients Record and its Implications in the Management of Trauma Patients

INTRODUCTION: A medical record audit is a type of quality assurance task which involves formal reviews and assessments of medical records to identify where a medical organization stands in relation to compliance and standards. A study was carried out with the objective to document the audit of the medical records in a tertiary care trauma center and suggest the corrective measures and preventive measures in case of lacunae. METHODOLOGY: A retrospective study was conducted in an apex trauma care facility of New Delhi. All the admissions on disaster bed from October 1, 2015, to December 31, 2015, were evaluated. A list of 106 admissions were made using the online software at the trauma center. The files were taken from the medical record departments and compared using a checklist prepared in accordance with the guidelines laid down by the Joint Commission International. RESULTS: A total of 106 admissions on disaster bed from October 1, 2015, to December 31, 2015, were evaluated. The average length of stay for the disaster beds was 11.7 days and the mortality rate was 9.5%. Signature of the patient and doctor and name of the witness were missing in more than 50% of the cases of consent. Discharge summary in which the investigation details, signature of the doctor, and contact number in case of an emergency were not documented. In the miscellaneous records, transfer (61%) and referral (42%) were not documented properly. CONCLUSION: The average length of stay for the disaster beds was 11.7 days. Maximum admissions were under the neurosurgery department. The filing and assembling of records were poor. Signature of the patient and doctor and name of the witness were missing in more than 50% of the consent forms. There was no anesthesia consent form used. The doctor daily records were poor, while the nursing records were well maintained. It is recommended to have a periodic weekly auditing to minimize chances of deficiency/misplacing of records. Periodic training sessions and workshops should be organized.