ABSTRACT
Background: Medical record document explains all the details about the patient’s history, clinical findings, diagnostic test results, pre- and post-operative care, patient’s progress, and medication given. If written correctly, notes will support the doctor about the correctness of treatment. Aim and Objectives: Our objective was to study effectiveness and utility of medical record department at our medical college affiliated tertiary care institution. Materials and Methods: We did an observational study to determine various parameters of medical records such as consent, history and examination findings, pre-operative and intraoperative records, investigation documentation, nursing care chart, and concerned medical person’s signature. The study included 300 files. A medical record checklist was used as a tool for data collection. The study was conducted between January 2021 and January 2022. Data were collected, entered in Microsoft Excel spread sheet, and analyzed using percentage. Results: Out of the 300 files, 186 files belonged to different surgical specialties while the rest were of non-surgical fields. It was found that nursing assessment document was present in 78%, while discharged card copy was found attached in 75.33% files. Furthermore, surgical safety checklist was found in 89.24%, while signature of faculty was absent in 38.3% files. Conclusion: Medical record maintaining and keeping is an essential and vital part of health-care infrastructure, not only for data collection but also for calculating use of resources needed for better delivery of quality services to patients.
ABSTRACT
Purpose: Effective communication lies at the heart of a patient--doctor relationship. Communication skills (CS) teaching and assessment is not a part of the postgraduate (PG) curriculum. Lack of effective CS in current PG students' results in patient distrust and dissatisfaction, conflicts, and compromised healthcare. The regulatory authorities of medical education have recognized the need to inculcate soft skills among medical graduates, one of which is CS. The purpose of this study was to assess the need for teaching CS to ophthalmology PG students and develop and introduce a module for the same. Methods: In this prospective, interventional study done at the ophthalmology department of a tertiary hospital, a validated 8 day CS workshop was conducted for 60 PG students through interactive lectures, observations, video sessions, and role plays. Feedbacks were obtained through narratives, validated Google survey, reflections and verbal method and analyzed. Results: In the needs assessment done on 27 departmental faculties, 20 faculties found poor communication to be a major reason for patient complaints. All faculties agreed that CS should be taught to medical students. Statistically significant improvement in CS awareness was noted among students after the workshop. Lack of CS training, work burden, and language were identified as main barriers to effective communication. All the students were satisfied with the workshop and wanted it to be conducted regularly. Conclusion: This study establishes that CS training is essential to improve patient satisfaction and patient-doctor relationships. Barriers to effective CS could be identified, for which possible solutions could be found.