Checklists for Review of Medical Records - NABH 5th Edition IMS.7 (Medial Audit in Hospital)

 

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INTRODUCTION

This blog article is in continuation of my previous blog about medical records review (medical audit in hospitals). To read the previous blog article click here

In this blog article, I will give you information on the various types of Checklists that are required for reviewing the medical records of patients (also known as Medical Audit Checklist), as per the requirements of IMS.7 NABH 5th Edition

SOME IMPORTANT MEDICAL AUDIT CHECKLISTS 

I have given the formats of some of the more prominent Checklists, without which the Medical Audit cannot be conducted. In addition to these, you may prepare Checklists (CL) of your own, as per your audit requirements

Since the review of medical records (Medical Audit) is carried out as per pre-defined parameters and clinical best practices (IMS.7-d), therefore, the Checklists should be prepared carefully, to ensure that every audit requirement is covered

I have given the formats of the following prominent Checklists

1. Documentation in patients’ records - audit this in both discharged files and admitted files
2. Clinico-Pathological and Clinico-Radiological co-relations - audit this in discharged files, and also admitted files, if possible
3. Conformance with Antibiotic Policy - audit this in discharged files, and also admitted files, if possible
4. Length of stay of surgery patients - audit this in discharged files

Checklist No.1

Checklist (CL) for documentation in patients’ records

In this Checklist include those documentation parameters which are mandatory as per NABH 5th edition

I have given just a few examples

This CL is common for both discharged files and admitted files

For individual case files, mark as NA (Not Applicable) whichever parameter is not applicable (examples - operative notes in cases of non-surgery patients, discharge summary in files of patients who are still admitted)

IP No. of patient xxxxxx	Discharged file OR Admitted file (tick whichever is applicable)		Date of scrutiny xxxx
Parameters	Evidenced in case file		Remarks, if any
	Yes	No
Medication orders are legible, dated, timed, signed, named (MOM.5-c)
Medication prescription written in all capitals (KPI parameter PSQ.3-d)
Entries in medical records are signed, named, dated, timed (IMS.3-e, IMS.3-f)
Medical records with incomplete and/or improper consent (KPI parameter PSQ.4-c)
Operation note is present in case file (COP.14-e)
Discharge summary is completely filled (AAC.14)
Copy of Discharge Summary present in case file (IMS.4-f)
Missing records in patient’s file (IMS.3-c)

Checklist No.2

Checklist for Clinico-Pathological / Clinico-Radiological co-relation

The Doctors / Surgeons and the heads of Pathology / Radiology departments should decide on the parameters that should be audited, as per requirements of NABH 5th edition, and any other requirement that you feel is important

PATHOLOGY DEPARTMENT

AAC.7-f states that the Laboratory Quality Assurance program should address clinico-pathological meetings

I have given example of a sample format below, as per my knowledge. Actually, the Doctors / Surgeons are the best persons to prepare this Checklist

IP No. of patient xxxxx	Discharged file OR Admitted file (tick whichever is applicable)	Date of scrutiny : xxxxx
Parameters	Tests recommended as per patient’s medical condition / treatment needs	Lab results found to be co-relating clinically		Treatment provided as per test results
		Yes	No	Yes	No
To be decided by qualified medical personnel		Give details here	Give details here	Give details here	Give details here

RADIOLOGY DEPARTMENT

AAC.10-f states that the Imaging Quality Assurance program should address clinico-radiological meetings

I have given example of a sample format below, as per my knowledge. Actually, the Doctors / Surgeons are the best persons to prepare this Checklist

IP No. of patient xxxxx	Discharged file OR Admitted file (tick whichever is applicable)	Date of scrutiny : xxxxx
Parameters	Investigations recommended as per patient’s medical condition / treatment needs	Investigation results found to be co-relating clinically		Treatment provided as per investigation results
		Yes	No	Yes	No
To be decided by qualified medical personnel		Give details here	Give details here	Give details here	Give details here

 

Checklist No.3

Checklist for Compliance with Anti-biotic Policy (HIC.3-e, HIC.3-f, HIC.3-g)

The Doctors / Surgeons and the Infection Control team should prepare this Checklist based on the parameters to be audited, as per the requirements of NABH 5th edition, and as per Anti-biotic policy requirements

Highly skilled medical personnel can only prepare this Checklist, so I have not given any sample format here

Checklist No.4

Checklist for Length of Stay of Surgery Patients (AAC.13-e, AAC.13-f)

Parameters related to this should be decided by the Surgeons / Doctors

For this, select a few surgery categories (examples - Total Knee Replacement, Caesarean Section delivery, Hernia, etc.). Decide upon the length of stay for each category of surgery patients

From discharged patients’ files for a period of 3 or 4 months, select a representative sample size of surgery files on random selection basis using statistical principles (if the number of surgeries has been few, then select all the files)

Given below is a sample format

Name of Surgery : xxxxx			IP No. of Patient  xxxxx		Defined length of stay : xxxxx days
Date of admission	Date of surgery	Date of discharge	Length of stay	Delayed by how many days	Reason for delayed discharge, if any	Reason for delayed discharge has been mentioned in the case file
					Here mention all the reasons, examples - patient developed post-surgery complications, discharge was delayed without any apparent reason, etc.	Here mention whether the reason for delayed discharge has been documented in the case file or not

 

The parameters given in the 4 above points are very important, which should be audited mandatorily

In addition to these, you may also include other parameters related to patient safety initiatives

Examples -

• Anaesthesia complications and actions taken (adverse anaesthesia events - COP.13-j)
• Scrutiny of Emergency Response Reports / Cardio-pulmonary resuscitation report (COP.5-d, COP.5-e, COP.5-f)
• Patients who received appropriate prophylactic antibiotics within the specified time frame (this is a KPI parameter PSQ.3-b)

NOTE :- my knowledge is based on my years of experience in the Administration department of a reputed super-speciality hospital in Mumbai. I am not a Doctor or a Nurse, but I write on topics which were a part of my job profile

I sincerely hope that you find this article helpful and informative

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