This document provides an overview of medical audits. It defines a medical audit as objectively evaluating the quality of medical care given to patients. The history of medical audits is discussed, noting some of the early pioneers in the field. Key materials for medical audits include medical records. Different types of audits are described, including internal audits done by medical records staff and external audits done by independent auditors. Methods, benefits, commonly found deficiencies, and overcoming deficiencies are outlined. The importance of complete, accurate medical records is emphasized for patient care, legal reasons, and quality assurance.

1. MEDICAL AUDIT

2. PRESENTED BY:
• SUDESHNA CHATTERJEE
• SABYASACHI MUKHERJEE
• SNEHA SAMANTA
• SENJUTI BANERJEE
• SUKANYA ROY RAKSHIT
• SOMA KUMAR

3. Introduction
DEFINITION:- The medical audit , which has been defined as an objective
method for applying a yard stick to the quality of perormances, is a method of
evaluating the quality of a medical care given to the patient, and its serves as
a tool to enable the hospital administrator and medical staff to uncover
inefficient service and point the way to the evaluation of standard in the
hospital.
HISTORY:-
1) George Gray Ward , probably inaugurated the first real medical audit in
United States in 1918 at women’s hospital , NEW YORK CITY.
2) In 1929, Thomas R. Ponton presented a plan for professional service
accounting and medical audit

4. MATERIAL OF MEDICAL AUDIT
• Medical records is an important document for medical audit.
• Dr. Malcom MacEachern known as the father of medical records.
Dr. J. R. McGibony has defined medical records as a clinical,
scientific, administrative and legal documents.
• Other factors contributing the quality of medical work.
1) Proper administration of the hospital
2) Objectives of medical audit

5. Methods of medical audit
• There are two phases of M.A.
• 1st phase includes the quantitative aspect by way of providing
adequate records of performance as a basic of analysis.
• 2nd phase is the qualitative aspect ,that is actual analysis of
recorded data in the clinical records, the filled reports
pertaining to the professional work of the hospital and other
related information.

6. types :
• Auditing can be performed by two ways:
1.Internal
2.External
Internal Audit
The qualitative aspects of medical auditing can be done by MRD or the medical
personnel who are specialized in the field. All the records of patients
discharged can be collected daily and arranged in a order, then the
deficiencies of each discharged records is listed in the deficiency slip.

7. External audit :
An external auditor performs an audit, in accordance with specific laws or rules,
of the financial statements of company, government entity, other legal entity, or
organization, and is independent of the entity being audited.
1.Medical audit committee can be performed in each hospital with 5-10
physicians/surgeons of good judgment fearless ,well skill in their fields selected
from major clinical services.
2.Hospital administrator can undertaken the medical audit work by conducting
monthly medical statistical meeting in the 1st/2nd week to discuss the hospital
statistics for the previous month including death, unimproved and interesting.

8. MEDICAL AUDIT SHEET :
The medical auditors have to design a medical audit sheet to record the
observations of auditors. Time of verification, the auditors will pay
attention to detect possible errors of diagnosis, treatment, judgment or
technique.
The work sheet used during the medical audit should neither becomes a
permanent part of medical records, nor it should be preserved.

9. BENEFITS OF MEDICAL AUDIT :
Medical audits if properly conducted will benefit for
1.The patient
2.The doctor
3.The hospital
4.The entire community

10. • WHAT IS COMPLETION OF RECORDS ? – It includes:
• Specificity and detail : Each diagnostic statement should be as informative as
possible in order to classify the condition to the most specific ICD category.
• Uncertain diagnosis or symptoms : If no definite diagnosis has been established by
the end of an episode of healthcare, then the information that permits the greatest
degree of specificity and knowledge about the condition that necessitated care or
investigation should be recorded. This should be done by stating abnormal finding
or problem, rather than qualifying a diagnosis as “possible”, “questionable” or
“suspected”, when it has been considered but not established.
• Multiple conditions : Where an episode of health care concerns a number of related
conditions (e.g. multiple injuries or multiple conditions occurring in human immuno
deficiency virus [HIV] diseases), the one that is clearly more severe and demanding
of resources than the others should b recorded as the “main condition” and the
others as “other conditions”. Where no one condition predominates, a term such as
“multiple fractures”, “multiple head injuries”, or “HIV disease resulting in multiple
infections” may be recorded as the “main condition”.

11. • Conditions due to external causes : When a condition such as an injury,
poisoning or other effect of external causes is recorded, it is important to
describe fully both the nature of the condition and the circumstances that
gave rise to it. For example : fracture of neck of femur caused by fall due to
slipping on greasy pavement. Cerebral contusion caused when patient lost
control of care, which hit a tree, accidental poisoning – patient drank
disinfectant in mistake for soft drink .
• Treatment of sequel : when an episode of care is for the treatment or
investigation of a residual condition (sequelae) of a disease that is no longer
present, the sequelae should be fully described and its origin stated, together
with a clear indication that the original disease is no longer present. For
example : deflated nasal septum – fracture of nose in childhood .

12. GUIDELINES FOR COMPLETION OF
RECORDS.

13. • STANDARDS FOR MEDICAL RECORD DOCUMENTATION:-
Maintain records that are documented accurately and in a timely
manner.
Readily accessible for prompt retrieval of information including
statistical data.
All significant records information pertaining to the patient must be
incorporated into the patients medical record.
Medical record must be sufficiently detailed and organized.

14. PATIENT MEDICAL RECORDS INCLUDE:
Complete and accurate identification of data.
 A Medical history completed within the first 24 hours of admission to in
patient services.
 IN A physician assessment completed within 24 hours of admission to
inpatient services.
 Evidence of appropriate informed consent.
 Reports of pathology and clinical laboratory examination as well as
radiology and nuclear medicines examinations.
 Reports of all diagnostic and therapeutic procedures.
 Progress notes and physicians orders.
 Consultation reports, if consulted.
 Anesthesia and operative reports in surgical cases.
 Discharge summary written at the termination of hospitalization concisely ,
recapitulating the reasons for hospitalization.

15. GENERAL INSTRUCTIONS
• Every sheet of each patient medical record must contain identification data
including at least the patient’s full name and hospital number.
• Unidentified forms without name and number should not be used.
• Indicated report is one that it is missing from the record but the record indicates a
report is necessary.
• Physicians order will identify whether a consultation was requested and missing
transcript of the report, may be noted as deficiency, radiology / lab reports ordered
by not found.
• Whenever documentation is done in medical record, the same should be
authenticated. Signatures are still the most common form of authentication.
• When medical record entries are made on a computer system, most system requires
the entry of a password or other form of identification . Very sophisticated
computer system may use finger prints or even retinal patterns as form of positive
identification.

16. • The face sheet should be attested by the Unit Chief, and all other dictated reports,
history and physical examination, discharge summary, progress notes, physicians
orders are to be attested by the doctor.
• Initials are acceptable a long as the initials are identifiable . Otherwise not to be
used.
• Rubber stamp with signature is allowed. In general, rubber stamps should be
avoided as stamp will be in the sole possession of the owner.
• Pre-signed forms, pre-signed forms should not be used.

17. GOOD RECORDING PRACTICES :
• Good recording practices are those measures which make the medical record
legible, readable, timely, without error, and reproducible.
• Legibility in general refers to handwriting.
• Readability is referred to he use of abbreviation and arrangement forms in the
medical record. Use only internationally acceptable approved abbreviations.
Abbreviations should not be used to document final diagnosis and procedure on the
face sheet. Only approved abbreviations are to be used in the content of the records.
• Timeliness of entries is critical to the accuracy of medical record. In addition,
authenticate date and time of entries.
• Correction of errors is extremely important from both a patient care standpoint and
legal aspects . Alteration of the medical record, the error must be circles and write
the correct entry below it, and then sign the new entry.
• Reproducibility means records being a dynamic document, it should be able to be
photocopied, microfilmed or scanned electronically for storage in the latest optical

18. COMMONLY FOUND DEFICIENCIES :
• Diagnosis without complete description; improper terminology
• Detailed diagnosis is written inside bit not on the face sheet
• Different final diagnosis recorded on the face sheet and discharge summary
• Discharge notes are not written or incomplete on the press notes. Instead of writing
“discharged only D is written
• No Provisional diagnosis on the history and physical examination record
• Commonly procedure / operations not recorded on the face sheet
• When provisional diagnosis and final diagnosis are same, it is documented as
“same as above”
• Result column is often not completed
• In most of the accident not written in RTA cases. EX. Head on Collision of cars.
• Usage of proper medical record forms
• Date and time of examination is not written.

19. DEFINITION OF DIAGNOSIS
• Diagnosis : It is made on the basis of extensive knowledge about the patient such as
family history, physical examination and investigation including X-rays and
laboratory test. The following are some of different kinds of diagnosis:
• Clinical Diagnosis : it is based upon symptoms shown during life, irrespective of the
morbid changes producing them.
• Principal Diagnosis : the condition established after study to be chiefly responsible
for occasioning the admission of the patient to the hospital for care.
• Pathological Diagnosis : based on gross and microscopic examinations of the
structural lesions present.
• Differential Diagnosis based on symptoms and physical signs of two contrasting
diseases.
• Preoperative Diagnosis : based upon findings observed during the operation. etc.

20. • COMPLETION OF RECORDS LEGALLY SPEAKING
CLINICAL AND CLERICAL
• The medical records is consists of patient identification data,
history, physical laboratory findings treatments including
surgical procedures and hospital course.
• When complete it should contain sufficient data to justify
investigations, diagnosis, treatment, length of hospital stay,
result and future course of action.

21. • Medical record is a backbone of health care system.
• Incomplete medical record are either inadequate, inaccurate, and
illegible document on various prescribed format or non filing of
the data in the desired format.
• Meet all the essential requirement for protection of patients as well
as staffs .
• Provide best health care.

22. Problems of incomplete records
Common omissions in the record.
Observed in the missing records.
In some cases investigation reports are available without physicians notes
showing any request or vice versa.
In case of clinical notes, they are not found in one place or in certain lines
are struck off are used instead of signatures
Corrections of the hospital number or name of the patient on the wrongly
filed investigation report by the doctors without verification add to the
deficiencies.
Reasons for records being deficient.
Common notion of a physician or surgeon generally it is provided to the
medical or surgical care to the clinical patient.

23. • Effects on patient care medical record being incomplete.
Discharge medication information must contain full details of patients
which will be easier for physicians for future course of action during
patients follow up.
Non availability of records and reports may result in patient history
investigation etc.

24. • If identification is incomplete.
 files will mixed up
Lead to serious problems like wrong diagnosis.
• Wrong treatment and wrong medication.
It will endanger the patients life.
Creating multiple files may lead to scattered of patient
information and duplication of information.
• One patient, one record, and one number policy is best for the
comprehensive and continue treatment of the patient.
• The health care providers will find it difficult to render quick
treatment during emergency due to lack of vital information thus
it will endanger patients life

25. • If allergic conditions of the patient are not highlighted or not
documented on the record it may endanger the patients life.
• Incomplete information will lead to delay in coding statistics etc.
as a settlement of third party and reimbursement claims.
• These records are difficult to issue a detailed medical report or
medical certificate to a later date.
• Appropriate documentation is required to prove the services
rendered to the patient are reasonably good and appropriate.
• Completion of incomplete records at a later date will be extremely
difficult due to many reasons e.g. change of doctors see too many
patients time factors etc.

26. OVERCOME THESE DEFICIENCIES
• Responsibility of doctors:
Complete records lie with the treating doctor.
Timely and prompt documentation of records immediately after attending the
patient is important.
• Responsibility of Nurse and Para medical staffs:
They should ensure that all related records of heir respective services should be
completed promptly

27. • Responsibility of administrators:
Provide proper facilities including transcription service for the MRD so that
medical and other staff can visit and complete the records promptly and
regularly.
• Responsibility of Medical Records officer :
Develop the following the clear cut written policies, standards and procedures
regarding completion of records; forms design and develop standard basic
medical record; effective maintenance of master patient index either
electronically or manually to avoid multiple files for on patient; keep the list of
doctors working in a hospital and their specimen signature for recognizing
the responsible doctors concerned easily to carried out quantitative and
qualitative

28. QUALITY ASSURANCE
• It is the broad term that encompasses several components i.e
Utilization Review, Medical Care Evaluation and Peer
Review. The following are considered important in relation to
medical record maintenance towards patient care and medical
record services.
•

29. • QUALITY : Richard Thompson defines quality as the optimal achievable
result for each patient. The avoidance of physician induced complication and
attention to patient and family needs in a manner that is both cost effective
and reasonably documented.
• QUALITY CONTROL : It is defined as those evaluation procedures that
are systematically to ensure established policies and standards are being met.
• QUANTITIVE ANALYSIS : It is the review of medical records to
ensure that they are complete and accurate and meet standards established
for them by the medical record committee. It is the responsibility of medical
record personnel to perform this analysis regularly on the records of patients
who have received care.
• QUALITATIVE ANALYSIS : It is the review of the records to ensure
that they contain sufficient information to justify the diagnosis, the treatment
and end result. Opinions are supported by laboratory findings and there are
no discrepancies or errors in recording healthcare information.

30. COMPUTER BASED PATIENT RECORDS
(CPR)
• In the present era of computers. The conventional manual
medical records are being replaced by electronic medical
records. As a result, Hospital are heading towards paper less
medical records. Even in this system, all the points discussed
above are applicable but only approach will be through the
computer. The main advantage is that completion of records
can be done in the respective workplace of the health care
providers.

31. •CONCLUSION
• The medical audit should function besides general medical staff
meetings, Departmental staff meetings and clinico-pathological
meetings. The group spirit and scientific attitude demonstrated in these
will enhance the role of the physician and promote the safe and
proficient care of the hospitalized patient. The first and foremost things
is to see that all the major hospitals give importance in establishing and
organizing the medical records department for scientific maintaining of
patient records. The medical staff of all hospitals should adopt minimum
standards for their medical records, and require each medical staff
members, to keep his record up to standard, and should audit its work.
The organized medical staff should also justify its work in terms of
morbidity and mortality and show that its success is consistent with
general average while failures were inevitable. The hospital medical
record which forms a part and parcel of the hospital property is used as a
legal document to detect negligence and the treatments rendered were
orb were not adequate and proper.

32. Contd..
• The completion of records is very much clinical and those who think it
clerical have been involved in legal litigation and suffered heavy damages.
Many physicians provide comprehensive and prompt care but avoid
documentation with the feeling that they will be dragged unnecessarily into
the legality. But conventional practice coupled with ineffective measures by
MRD and administration ,the patients are rendered care while their records
are either kept incomplete or completed after a laps of time; regarding from
days to weeks and months . Accurate and complete records can result which
will serve for medico legal, medical education ,research besides continuing
patient care that will be cost effective. Consequently ,the information
generated from these records could be an excellent ,means for proper
planning ,management and evaluation of patient care as well as health care
organization.

33. Thank you