MEDICAL AUDIT FORMAT

Particulars
UHID number documented

Documentation of final diagnosis with ICD code on the face sheet

Discharge / Referral / Death – signed, named, dated and timed by treating

doctor
General consent signed by the Medical Officer affixed with name, date and
time.
General consent signed by the patient / family / attendant and affixed with
name, date and time
TPR chart documented in graphic format indicating of number of in-patient
days, BP, weight, etc.
Nutritional screening done by the staff nurse

Documentation of pain intensity score in VDS in Nursing assessment

Nursing care plan documented by staff nurse affixed with sign, name, date
and time
Medical officer’s name, date and time at the beginning of Initial
Assessment.
Provisional diagnosis documented by the treating doctor

Documentation of treatment plan, goals and objectives by the treating doctor

Dietary advice documented by the treating doctor

Medical prescriptions written in a comprehendible manner in uniform
location, duly signed, by the treating doctor
Error prone abbreviations used in medical prescriptions

Informed consents duly signed, named, dated and timed by the patient /
family / attendant with documentation of relationship to the patient.

Lab investigations reports provided in a standardized report format duly

signed, named, dated and timed by the Lab technician and Medical Officer
i/c of Lab.
Documentation of date of collection, date of expiry, screening tests results,
blood group and type in the blood cross matching form duly signed, named
and dated by the Medical Officer
Documentation of blood transfusion procedure by treating doctor regarding
starting time, completion time and post transfusion reaction, if any in the
patients’ medical records
Post transfusion reaction form with details documented and duly signed,
named and dated by the staff nurse and treating doctor.
Referral notes with signature of the Medical Officer affixed with name, date
and time.
Time and signature of staff nurse documented in the medication
administration chart
Nurses’ report with signature of the staff nurse affixed with name and date
Partograph with details signed by the staff nurse affixed with name, date and
time
Safe Birth Delivery checklist used for maternal care patients
Physiotherapy assessment and re-assessment documented, signed, named
and dated by the physiotherapist affixed with name, date and time
Patient’s name, UHID number, IP number, age, sex, ward details, hospital
name and medical record sheet number documented on the continuation
sheet of the medical record
Documentation of patient transfer to other hospitals – details of date of
transfer, reason for transfer and name of the receiving hospital.
Chronological order of patient care documentation
Completeness and Legibility
Discharge summary contents
a) Patient’s name, age, sex, ward, IP number, UHID number, DOA,
DOS, DOD documented
b) ICD codification of final diagnosis, operation and / or procedure
c) Documentation of investigations done with reports
d) Documentation of any procedures done (Biopsy, Lumbar Puncture,
ICD, etc)
e) Documentation of medications administered during treatment
f) Condition of patient at the time of discharge
g) Follow-up advice – Medications to be written in simple format – in an
understandable manner
h) Diet advice documented in discharge summary
i) Information regarding “when” and “how” the patient shall seek urgent
medical care