Bhatia Global Hospital

Medical Care Audit

Identification data for inpatient to which this case sheet pertains:

1. Date of audit:-

2. Patients Name:-

3. Registration No:-

4. Diagnosis on admission:-

5. Final diagnosis:-

6. No. of days in hospital:-

7. Discharge/Expired/LAMA/Transferred/Absconded:-

Particulars of Clinician treating

1. Doctor’s (Speciality) Name:-

2. Status (Consultant / Medical Officer)

 Relating to records / diagnosis / treatment / results etc

 Is the initial assessment form filled completely? Yes No

 Are the records duly named, signed, dated and timed by the concerned doctor? Yes No
 Are history, physical examination, diagnosis and treatment details available? Yes No
 Are the laboratory and radiographic reports attached and entered in the record? Yes No
 Are the progress notes sufficient and relevant so that the clinical course can be followed? Yes No
 Has the summary of the case been recorded at the time of discharge? Yes No
 Whether a provisional diagnosis was made and enclosed after the admission? Yes No NA
 Whether a provisional diagnosis tallies with the final diagnosis? Yes No NA
 Whether investigation findings support final diagnosis? Yes No NA
 Are laboratory investigations sufficient in relation to nature and gradient of illness? Yes No NA
 Are the Operation / anesthesia notes adequate? Yes No NA
 If the case required consultation by other specialists was the same sought for? Yes No NA
 Whether there was adequate indication for surgery? Yes No NA
 Whether the patient; refusal to undergo a prescribe treatment was justifiable? Yes No NA
 In case of death, whether it was expected, justifiable or not? Yes No NA
 Was the complication justifiable or not? Yes No NA
 Whether there was any hospital cross infection which could have been avoided? Yes No NA
 Whether there was any anesthetic complication which could have been avoided? Yes No NA
 Was consent for anesthesia and operation obtained? Yes No NA
 Was pre-anesthetic assessment for anesthesia done and recorded? Yes No NA
 Was there any in ordinate delay between admission and surgical operation? Yes No NA
 Whether post event analysis of CPR conducted and recorded? Yes No NA
 Whether post event analysis of blood transfusion conducted and recorded? Yes No NA