Abstract
Background: Death Audit needs to be conducted frequently in all hospitals to check IPD (Indoor Patient Department) files for qualitative and quantitative adequacy.
Various parameters used to check Death files are (a) correctness of diagnosis (b) Adequacy of Investigations (c) Promptness & Adequacy of treatment in comparison to normal standard (d) Correctness and completeness of documentation.
Aims and Objectives: To study impact of conduct of monthly Death Audit in Medicine Department in improving standard of documentation by doctors.
Methodology: The present study was a Record based, Interventional study covering 5 calendar years. After obtaining permission of institutional ethics committee, documentation errors in 1198 Death files [87.38% of total death files between 2014 to 2018], were studied. Data obtained was analyzed by Chisquare Test.
Results: Errors rates were reduced in most of 18 parameters used to check Death Files and in many parameters reduction is statistically significant.
Discussion: Tenure of junior residency is best phase of doctors, to develop habit of correct and complete documentation in all IPD files. In a teaching hospital monthly Death Audit meets can be used as a tool of Medical Education Technology (MET), to teach JRs (Junior Residents) about need and method of documentation, so that they are competent to avoid legal problems in their careers.
Conclusions: Meticulous record keeping is required to avoid observations from various courts, insurance and empanelment agencies, Government Health officials and NABH inspectors.
Keywords: Death Audit, Error Rates, Documentation, Legal Issue.
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Corresponding Author
Dr Nalini Humaney
Professor & amp; HOD Medicine, NKP Salve Institute of Medical Sciences & Research Centre, Nagpur-440019, India
DOI: https://dx.doi.org/10.18535/jmscr/v7i12.28
