Title: Comparative Study of Errors of Documentation by Junior Residents in Medical Records of Patients, Who Died in Medical Intensive Care Unit of 1000 Bedded Teaching Hospital in Year 2014-2015
Authors: Vivek K. Pande, Aniket Saoji, Jaydeep Nayse
DOI: http://dx.doi.org/10.18535/jmscr/v4i4.02
Aims and Objectives: To study errors of documentation by junior residents (JRs) and to compare error rates of year 2014 with year 2015. Methodology: This study was interventional, record based, prospective, cross sectional study, with duration of two year from January 2014 to December 2015. After obtaining approval from Institutional Ethics Committee, a total of 222 death file of year 2014 and 240 death files of year 2015 of Medical intensive care unit(MICU) were obtained from Medical Record Department(MRD) of Lata Mangeshkar Hospital, Hingna, Nagpur. In the year 2015 regular monthly death audit meetings were conducted to overcome fallacies noticed in 2014. Data obtained was analyzed by chi square test. Results: Statistically significant improvement was seen in parameters like daily revised treatment notes, name of Dead body (DB) and death Certificate (DC) receiver, procedure notes, Relation of DB and DC receiver with deceased, time of DB & DC handing over, daily progress notes, date of DB & DC handing over, senior review of USG/CT/MRI and signature of senior resident/lecturer on death summary. Discussion: Error rates were reduced in 2015 as compared to 2014, which is attributed to detailed discussion of errors and proper training of JR’s in medical record keeping. Conclusion: Meticulous record keeping is needed to avoid observations from various agencies like consumer forum, insurance agencies and government health authorities and to improve health care provision in general. It is possible with proper training of junior residents. Key Words: Record keeping, Error rates 1. Medical Record Administration and Healthcare Documentation, Rapid Action Revision (RAR) Issue, retrieved from http://www. apd.army.mil/pdffiles/r40_ 66.pdf[last updated on 4/02/2010]. 2. CG2–Record Keeping Guidelines, retrieved from http:// www. nhsprofessionals.nhs.uk/download/comms/cg2%20-%20record%20 keeping%20clinical%20guidelines.pdf. 3. Tiwari S. Record keeping In Textbook of Medico-legal Issues Related to Various Medical Specialities editor Nilofer Mujawar, Jaypee brothers medical publishers, New Delhi 2012: 49-52. 4. Weed L. Medical records that guide and teach. N Engl J Med 1968; 278:652-7. 5. Nursing documentation, record keeping and written communication, Elsevier Health retrieved from https:// www.us.elsevier.health.com/media/us/sample chapters/9780443073991/9780443073991.pdf. 6. “Statement on Consistency of Healthcare Diagnostic and Procedural Coding.”AHIMA Position Statement, retrieved from www. ahima.org. [last updated on December 2010].4 7. “Developing a Coding Compliance Policy Document (Updated).” Journal of AHIMA, retrieved from www.ahima.org. [Updated on March 2010]. 8. Cassidy BS. Defining the core clinical documentation set for coding compliance, retrieved from http://library.ahima.org/expedio/groups/public/documents/ahima/bok1 049822.pdf. 9. Dimond B. Legal aspects of documentation. Exploring common deficiencies that occur in record keeping. British Journal of Nursing 2008; 14(10):568-71. 10. Bodek H. Basic Standards for Clinical Documentation and Record Keeping, The New York State Society for Clinical Social Work, Inc. downloaded from http://www. clinicalsw.org/basic_ standards.html. 11. Bargaje C. Good documentation practice in clinical research. Persp Clin Res 2011;2(2):59-63. 12. Health care records- documentation and management, retrieved from http://www0.health.nsw.gov.au/policies/pd/2012/pdf/ PD2012_069.pdf. 13. Legal Medical Record Standards, retrieved from http://policy. ucop.edu/doc/1100168/ Legal Medical Record. 14. A Guide to Better Physician Documentation, retrieved from http://www.health.gov.on.ca/transformation/providers/information/pdf/guide_bpd.pdf 15. Roach JR, William H. Medical Records and the Law, 3rd ed, Aspen Health Law and Compliance Centre;1998:30-32. 16. Sinha S, McDermott F, Srinivas G et al. Use of abbreviations by health care professionals: what is way forward? Postgrad Med J 2011;87(1029):450-2. 17. Carroll AE, Tarczy-Hornoch P, O’Reilly E et al. Resident documentation discrepancies in a neonatal intensive care unit. Pediatrics 2003;111(5.1):976-80. 18. Hameed F. Are there any approved medical abbreviations? Br Med J;2012:344. 19. Saraliya PK, Satish NT, Harish S. Consumer Protection Act and Medical negligence; an update. Journal of Indian Medical Association 2009;111(7):468-71. Abstract
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