Professional Documents
Culture Documents
Medical Records Audit Checklist
Medical Records Audit Checklist
Medical Records Audit Checklist
2 Admission forms
2.1 IP No./OP No
2.2 Patient details
2.3 All pages has patient ID
2.4 Name of Emergency Contact & Phone Number
noted in record;
2.5 DOA and time
2.6 DODischarge and time
2.7 Provisional diagnosis
2.8 Final diagnosis
2.9 Operation procedure and date
2.10 Discharge status
2.11 ICD code
2.12 Cause of death if applicable
2.13 Signature of the doctor
3 General consent form
5.1 History
5.2 Allergies / Adverse Reactions noted
5.3 Current list of medications is noted
5.4 Examination
5.5 Provisional diagnosis: a. In full detail
b. Any Abbreviation
5.6 Investigations ordered entered in record
5.7 Final diagnosis : a. In full detail
b. Any Abbreviation
5.8 Doctors daily notes and observations
5.9 Entry of Investigations reports & Treatment
advised
5.10 Doctors signatures with date and time
6 Nurse’s record
9 Discharge summaries
9.1 Chief complaint, past history, physical
examination
9.2 Medication and Treatment given
9.3 Condition at discharge
9.4 Date or time for next follow up
9.5 Discharge medication or any advice on the
discharge
9.6 Signature of the doctor