Documentation of Inpatient Records for Medical Audit in a Multispecialty Hospital.

Introduction: Medical audit in the current scenario of increasing medical demands and the increasing trend of medical multispecialty has been a crucial tool to analyse and regulate the service provided to the service receiver or the patient. Medical Records can be defined as the set of documents that provide the clinical, para-clinical, and financial data about the patient. Materials and Methods: The study was conducted for a period of one year in our own teaching hospital (Teerthanker Mahaveer Medical College, Hospital & Research Centre, Moradabad, Uttar Pradesh, India) which is tertiary care Centre with 900 functional beds, in the urban area of the state to analyse the documentation of medical audit. The data so collected was through brainstorming, observation, interview, and review of workflow during the lean sessions was conducted. Results: The intensity of difference among the standard of record keeping in various departments was actually surprising. First of all the department of Paediatrics and gynaecology was found to be most satisfactory while general medicine department was not at all in order. Conclusion: This study showed that in order to achieve patient's satisfaction, the correct measurement of the quality of the services being offered to the patients is the basic quality of the medical service provider. [ABSTRACT FROM AUTHOR]