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Medical Records Audit Checklist

1 Name and ID on Medical record: 2 Admission forms 2.1 IP No./OP No 2.2 Patient details 2.3 All pages has patient ID 2.4 Name of Emergency Contact & Phone Number noted in record; 2.5 DOA and time 2.6 DODischarge and time 2.7 Provisional diagnosis 2.8 Final diagnosis 2.9 Operation procedure and date 2.10 Discharge status 2.11 ICD code 2.12 Cause of death if applicable 2.13 Signature of the doctor 3 General consent form 3.1 Patient name with details 3.2 Signature of the patient/relative/guardian with date 3.3 Signature of the doctor with date 3.4 Signature of the witness 3.5 Language 4 Special Consent 4.1 Patient profile (IP no, Name, Department) 4.2 Name and signature of the patient/relative/guardian 4.3 Signature of the witness with date 4.4 Signature of the performing doctor with date 4.5 Indication of surgery/procedure 5 Clinical Department: ________Unit:____

5.1 History 5.2 Allergies / Adverse Reactions noted 5.3 Current list of medications is noted 5.4 Examination 5.5 Provisional diagnosis: a. In full detail b. Any Abbreviation 5.6 Investigations ordered entered in record 5.7 Final diagnosis : a. In full detail b. Any Abbreviation

5.8 Doctors daily notes and observations 5.9 Entry of Investigations reports & Treatment advised 5.10 Doctors signatures with date and time 6 Nurses record

6.1 Treatment protocol/ Medication chart 6.2 Observations a. TPR Chart b. Input /Output chart c. Recording Vitals 6.3 Concurrence of doctors orders Date, time and signature 7. Anesthesia Management Form

7.1 Patient profile documented 7.2 Signature of the doctor with name and date 7.3 Pre anaesthetic assessment 7.4 Anaesthesia used documented 7.5 Signature of the doctor 8. Postoperative notes

8.1 Surgery, date and time 8.2 Surgical notes 8.3 Post operative instructions and follow up 8.4 Signature and date by the doctor 8.5 Pre operative diagnosis tallies with the post operative 9 Discharge summaries 9.1 Chief complaint, past history, physical examination 9.2 Medication and Treatment given 9.3 Condition at discharge 9.4 Date or time for next follow up 9.5 Discharge medication or any advice on the discharge 9.6 Signature of the doctor