Medical Records Audit Checklist

1 Name and ID on Medical record: Department: ________Unit:____

2 Admission forms 2.1 IP No./OP No 2.2 Patient details2.3 All pages has patient ID2.4 Name of Emergency Contact & Phone Number noted in record;2.5 DOA and time2.6 DODischarge and time2.7 Provisional diagnosis2.8 Final diagnosis2.9 Operation procedure and date2.10 Discharge status2.11 ICD code2.12 Cause of death if applicable2.13 Signature of the doctor

3 General consent form

3.1 Patient name with details3.2 Signature of the patient/relative/guardian with date 3.3 Signature of the doctor with date 3.4 Signature of the witness3.5 Language4 Special Consent

4.1 Patient profile (IP no, Name, Department) 4.2 Name and signature of the patient/relative/guardian 4.3 Signature of the witness with date 4.4 Signature of the performing doctor with date 4.5 Indication of surgery/procedure

5 Clinical

5.1 History5.2 Allergies / Adverse Reactions noted5.3 Current list of medications is noted5.4 Examination5.5 Provisional diagnosis: a. In full detail b. Any Abbreviation 5.6 Investigations ordered entered in record5.7 Final diagnosis : a. In full detail b. Any Abbreviation

5.8 Doctors daily notes and observations5.9 Entry of Investigations reports & Treatment advised5.10 Doctors signatures with date and time

6 Nurse’s record

6.1 Treatment protocol/ Medication chart 6.2 Observations a. TPR Chart

b. Input /Output chartc. Recording Vitals

6.3 Concurrence of doctors orders Date, time and signature

7. Anesthesia Management Form

7.1 Patient profile documented 7.2 Signature of the doctor with name and date 7.3 Pre anaesthetic assessment 7.4 Anaesthesia used documented 7.5 Signature of the doctor

8. Postoperative notes

8.1 Surgery, date and time 8.2 Surgical notes 8.3 Post operative instructions and follow up 8.4 Signature and date by the doctor 8.5 Pre operative diagnosis tallies with the post operative

9 Discharge summaries9.1 Chief complaint, past history, physical examination 9.2 Medication and Treatment given 9.3 Condition at discharge 9.4 Date or time for next follow up 9.5 Discharge medication or any advice on the discharge 9.6 Signature of the doctor