PRACTICE OF DOCUMENTATION AT CASUALTY OF TERTIARY CARE HOSPITAL – AN INTERVENTIONAL STUDY

Abstract

A medical record plays a major role for the patient and health care sector in terms of treatment and making
policies on certain diseases. In any suit of negligence, this medical record will help the doctors to defend
them. Many a times the complete and accurate documentation only have helped the medical fraternities
from getting entangled in various consumer cases made by the patient against the doctors. Even though we
have seen so many negligence cases on doctors, documentations are still incomplete in any medical record.
There are studies shown that the average time spent by a doctor on a medical record is very less and the
scenario is much worse when it comes to critical areas of the hospitals like casualty where the time is very
precious in treating the patient and not much of importance is given for documentation. So to identify the
current practice of documentation of medical records, this study was carried out to assess the documentation
practice of the admission case sheets in the casualty of SMVMCH, Puducherry. An intervention was done
to improve the completeness of documentation in the casualty and post-intervention analysis was also done.
The results of the study showed that the percentage of documentation out of the 34 variables documented in
the admission case sheets found to have significant deficiencies. But following the intervention on improving
the documentation there has be a significant decrease of the deficiencies in the documentation practice on
all those 34 variables.