‘Medical audit is defined as evaluation of medical

care in retrospective through analysis of medical

records. It involves assessment of current
performance against sets standards’
 Involves systemic approach
 Highlights opportunities for improvement
 Provides Mechanism of change
 Is different from case presentation morbidity,
mortality and infection
 CLINICAL AUDIT
Assessment of followed cases

 Structure – Type of resource

 Process – What is done to the patient
 Outcome – the result of clinical evaluation
 AUDIT CYCLE
Observation of existing procedure
 Setting of standards
 Comparison between observed and set standards
 Implementation of change
 Re-audit of clinical practice
 MEDICAL AUDIT BASED ON
1. What did the patient have?
2. What was done for patient?
3. Was something that was required to be done,
not done, if not, why not?
4. Was the treatment optimum? If not, why not?
5. Was the outcome satisfactory? If not, why not?
 MEDICAL AUDIT
Identification Data for Inpatient to whom this case
sheet pertains :
1. Name ………………………….
2. Address………………………….
3. Central registry No. ……………
4. Ward No………………5. Bed No. …………….
6. Diagnosis on admission ………………………..
7. Final diagnosis
8. No. of days in hospital
9. Disposal –(Discharge/Died/LAMA /Transferred)
……………………………
 PARTICULARS OF CLINICIAN
TREATING THE CASE
1. Dr. ………………………………….
Specialty…………………………….
2. Status……………………….(Professor, Reader,
Lecturer, Senior Registrar, Junior Registrar, etc.)
 ATTRIBUTES OF THE CASE
Relating to the Records
1. Are the records properly filled? :
Yes/No
2. Are history, physical examination, : Yes/No
diagnosis and treatment details available?
3. Are the laboratory and radiographic reports : Yes/No
attached and entered in the record at
appropriate place
4. Are the progress notes sufficient and : Yes/No
relevant that the clinical course can be followed
5. Has the summary of the case been recorded : Yes/No
at the time of discharge?
6. Whether a provisional diagnosis was made : Yes/No
and endorsed after the admission?
7. Whether the provisional diagnosis tallies : Yes/No
With the final diagnosis?
8. Whether laboratory findings support final :
Yes/No
Diagnosis?
9. Whether radiological findings support final : Yes/No
Diagnosis?
10. Are laboratory investigations sufficient in : Yes/No
Relation to nature and gradient of illness?
11. Was any laboratory investigation : Yes/No
Unnecessarily asked for?
13.Was any radiological examination indicated :Yes/No
And yet not asked for?
14. Whether the preoperative diagnosis tallies :Yes/No
With the post operative diagnosis?
15. Whether the autopsy findings tally with the :Yes/No
clinical diagnosis?
16. Whether the autopsy findings tally with the :Yes/No
Pathological diagnosis?
17. Whether the autopsy findings tally with :Yes/No
Radiological diagnosis?
18. Was there any avoidable delay in arriving at :Yes/No
The diagnosis?
Relating to Treatment
19. Are the operation notes adequate? :Yes/No
20. Are the Anaesthesia notes adequate? :Yes/No
21. If the case required consultation by other :Yes/No
specialists, was the same sought for?
22. Was the treatment given generally :Yes/No
acceptable or open to question?
23. Whether the overall treatment given to the patient can :Yes/No
be judged from the data endorsed in the medical record
24. Whether the clinician exceeded the privilege :Yes/No
or limits of his or her training and competence?
25. Whether there was adequate indication for surgery? :Yes/No
26. Whether any normal organ or tissue Removed? :Yes/No
27. Whether any part of the treatment given was Superfluous? :Yes/No
28. Whether the patient refusal to under go a :Yes/No
Prescribed treatment was justifiable?
Relating to End result

29. Was the final result in consonance

:Yes/No
with the Nature of the case and
expected prognosis?
30. In case of death, whether it was expected, :Yes/No
Justifiable or not?
31. Were the complications justifiable or not? :Yes/No
Relating to Complication and Cross-infection
32. Whether there was any hospital cross :Yes/No
Infection which could have been avoided?
33. Whether there was postoperative infection :Yes/No
Which can be avoided?
34. Whether there was a complication because :Yes/No
Of faulty surgical operation?
35. Whether there was postoperative :Yes/No
Complication which could have been avoided?
36. Whether there was any anesthetic :Yes/No
Complication which could have been avoided?
Relating to Operation Cases

37. Was consent for Anaesthesia and :Yes/No

operation obtained?
38. Was there adequate indication for surgery? :Yes/No
39. Was any normal tissue removed and if so :Yes/No
was it justified?
40. Was preanaesthetic assessment for :Yes/No
Anaesthesia done and recorded?
Relating to the Length of Stay of Patient
41. Was there any inordinate delay between :Yes/No
admission and surgical operation?
42. Whether there was inordinate delay :Yes/No
between admission and commencement of
specific/definitive treatment?
43. Whether there was inordinate delay :Yes/No
Between admission and ordering of laboratory
or radiological investigations?
44. Whether there was inordinate delay in :Yes/No
Arriving at final diagnosis?
45. Was the length of stay of the patient in :Yes/No
Hospital longer than was really necessary?
46. Did he or she develop any aliment during :Yes/No
Stay in hospital necessitating longer stay?