Abstract
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
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Corresponding Author
Vivek K. Pande
Associate Professor, Dept of Medicine,
NKP Salve Institute of Medical Sciences and Research Centre,
Nagpur, MS, India
DOI: http://dx.doi.org/10.18535/jmscr/v4i4.02
