Audit of medical records keeping at a Nigerian geriatric clinic

RESUMO

BACKGROUND: A medical record also known as health chart is the written health information about a patient or clients and is always opened whenever a patient or client visits a health facility. There are different types of medical records and it may be problem based or patient based; paper based or electronic. It enhances continuity of care; source of communication between healthcare professionals, as aides de memoire and it is a legal document. OBJECTIVE: To compare the medical records keeping with reference standards. METHOD: This is a prospective clinical audit, was conducted in a Nigerian Nursing Home for the elderly. The medical record keeping was compared with the generic standards of medicalrecordkeepingofthehealthinformatics Unitof the Royal College of Physicians. Two clinical audit cycles were performed. results: At the first clinical audit cycle only the third standard was 50%, others were zero. At the second clinical audit cycle there was improvement and 100% increase in standard 1, 3, 4 and 5, with 10% increase in standard 2. Paper based medical records are kept at the nursing home. Most of the residents do not know their age as their birth dates was not recorded. There were 30 residents at the nursing home when the clinical audit was conducted. CONCLUSION: Initially, the medical record keeping was below standard but with the clinical audit there was improvement. Clinical audit is important in medical practice in comparing the practice with standards