Audit of medical record documentation of patients admitted to a medical unit in a teaching hospital NWFP Pakistan

To audit the medical record documentation of patients admitted to a medical unit in year 2005 at a teaching hospital NWFP Pakistan. The retrospective audit was conducted in the Medical [C] Unit of Government Lady Reading Hospital Peshawar from 1st January 2005 to 31st December 2005. Out of 3944 patients admitted during 2005, 200 case notes were randomly selected and subjected to audit. The clinical notes were broadly analysed for documentation of six parameters. Each parameter's documentation was to be graded as very good, good, average, poor, or not documented. Personal bio-data was documented good in 194 [97%] cases; history and examination were good in 22 [11%] cases; diagnosis was very good in 48 [24%] cases; Investigation were documented very good in 18 [9%] cases and good in 134 [67%] cases; Progress notes were good in 156 [78%] cases and treatment was documented good in 186 [93%] cases. In 82 [41%] charts, one or more of the six selected items were not documented at all. Investigations were not written in 20%, progress notes in 12%, history and examination in 9%, diagnosis in 6%, treatment in 3% and bio-data in 1% of the case notes. Documentation of important clinical information is poor even in the hospital charts of patients admitted in tertiary care hospital. Poor documentation in medical records might reduce the quality of care and undermine analyses based on retrospective chart reviews