SAHDEO HOSPITAL

Medical Audit Check List (Surgical case)

Date of audit: IP No: UHID No: Age /Sex:

Sl.No. Particulars Yes No NA

1. UHID number documented
2. Documentation of final diagnosis with ICD code on the face sheet
3. Discharge / Referral / Death – signed, named, dated and timed by treating doctor
4. General consent signed by the Medical Officer affixed with name, date and time.
5. General consent signed by the patient / family / attendant and affixed with name, date
and time
6. TPR chart documented in graphic format indicating of number of in-patient days, BP,
weight, etc. signed by the staff nurse
7. Nutritional screening done by the staff nurse
8. Documentation of pain intensity score in VDS in Nursing assessment
9. Nursing care plan documented by staff nurse affixed with sign, name, date and time
10. Medical officer’s name, date and time at the beginning of Initial Assessment.
11. Provisional diagnosis documented by the treating doctor
12. Documentation of treatment plan, goals and objectives by the treating doctor
13. Dietary advice documented by the treating doctor
14. Medical prescriptions written in a comprehendible manner in uniform location, duly
signed, named, dated and timed by the treating doctor
15. Error prone abbreviations used in medical prescriptions
16. Informed consents duly signed, named, dated and timed by the patient / family /
attendant with documentation of relationship to the patient.
17. Surgery consent contains doctor’s name, procedure name, details of risk,
complications, alternate procedures, signed, dated and timed by the treating doctor
18. Anaesthesia consent signed, named, dated and timed by the anaesthetist
19. Anaesthesia plan and risk documented in pre-anaesthesia assessment with
anesthetists’ sign, name, date and time
20. Results of infective bacterial and viral diseases documented in the pre-operative
check list
21. 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.
22. Pre-induction assessment signed, named, dated and timed by anaesthetist
23. PR, BP, RR, Sp O 2, temperature documented, signed, named and dated by
anaesthetist in anaesthesia working sheet
24. Pain intensity score documented in the pain management document
 25. Aldrete’s score / PADS duly signed, named, dated and timed by anaesthetist
26. Operative notes documented, signed, named, dated and timed by operation surgeon
27. 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
28. Documentation of blood transfusion procedure by treating doctor regarding starting
time, completion time and post transfusion reaction, if any in the patients’ medical
records
29. Post transfusion reaction form with details documented and duly signed, named and
dated by the staff nurse and treating doctor.
30. Referral notes with signature of the Medical Officer affixed with name, date and time.
31. Time and signature of staff nurse documented in the medication administration chart
32. Nurses reports with signature of the staff nurse affixed with name, date and time
33. Physiotherapy assessment and re-assessment documented, signed, named and dated
by the physiotherapist affixed with name, date and time
34. 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
35. Documentation of patient transfer to other hospitals – details of date of transfer,
reason for transfer and name of the receiving hospital
36. Up-to-date and chronological account of patient care
37. Completeness and Legibility
38. 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 surgical procedure done with salient operative findings
e) Documentation of medications administered
f) Condition of patient at the time of discharge
g) Follow-up advice – Medications to 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

Name and signature of auditor: