Medical Audit : M.

PALADA Month: NOV 2020

1 2 3 4 5 6 7 8 9 10
(2) No. Not
(1) No. Fulfilled (3) No. Not
No ITEM Fulfilled (no
Yes NO (No. of yes) Applicable
of Nos)

1 UHID number documented 1 1 1 1 1 1 1 1 1 1

2 Documentation of final diagnosis with ICD code on the face sheet 0 0 0 0 0 0 0 0 0 0
3 Discharge / Referral / Death – signed, named, dated and timed 1 1 1 1 1 1 1 1 1 1
by treating doctor
4 General consent signed by the Medical Officer affixed with name, 1 1 1 1 1 1 1 1 1 1
date and time.
5 General consent signed by the patient / family / attendant and 1 1 1 1 1 1 1 1 1 1
affixed with name, date and time
6 TPR chart documented in graphic format indicating of number of 0 0 0 0 0 0 0 0 0 0
in-patient
Nutritionaldays, BP, weight,
screening done byetc.
thesigned by the staff nurse
staff nurse
7 0 0 0 0 0 0 0 0 0 0
8 Documentation of pain intensity score in VDS in Nursing 0 0 0 0 0 0 0 0 0 0
assessment
Nursing care plan documented by staff nurse affixed with sign,
9 0 0 0 0 0 0 0 0 0 0
name,
Medicaldate and time
officer’s name, date and time at the beginning of Initial
10 1 1 1 1 1 1 1 1 1 1
Assessment.
11 Provisional diagnosis documented by the treating doctor 0 0 0 0 0 0 0 0 0 0
12 Documentation of treatment plan, goals and objectives by the 1 1 1 1 1 1 1 1 1 1
treating doctor
13 Dietary advice documented by the treating doctor 0 0 0 0 0 0 0 0 0 0
14 Medical prescriptions written in a comprehendible manner in 1 1 1 1 1 1 1 1 1 1
uniform location, duly signed, named, dated and timed by the
15 Error prone abbreviations used in medical prescriptions 1 1 1 1 1 1 1 1 1 1
16 Informed consents duly signed, named, dated and timed by the 1 1 1 1 1 1 1 1 1 1
patient / family / attendant with documentation of relationship
17 Lab investigations reports provided in a standardized report NA NA NA NA NA NA NA NA NA NA
format duly signed,
Documentation named,
of date dated anddate
of collection, timed by the Lab
of expiry, screening
18 NA NA NA NA NA NA NA NA NA NA
tests results, blood group and type in the blood cross matching
19 Referral
form dulynotes withnamed
signed, signature
and of the Medical
dated Officer Officer
by the Medical affixed with NA NA NA NA NA NA NA NA NA NA
name, date and time.
20 Time and signature of staff nurse documented in the medication 0 0 0 0 0 0 0 0 0 0
administration chart
21 Nurses’ report with signature of the staff nurse affixed with name 0 0 0 0 0 0 0 0 0 0
and date
22 Partograph with details signed by the staff nurse affixed with NA NA NA NA NA NA NA NA NA NA
name, date and time
23 Physiotherapy assessment and re-assessment documented, NA NA NA NA NA NA NA NA NA NA
signed, named and dated by the physiotherapist affixed with
24 Patient’s
name, datename,
and UHID
time number, IP number, age, sex, ward details, 1 1 1 1 1 1 1 1 1 1
hospital name and medical record sheet number documented on
25 Documentation
the continuationofsheet
patient transfer
of the to other
medical hospitals – details of
record NA NA NA NA NA NA NA NA NA NA
date of transfer, reason for transfer and name of the receiving
26 Up-to-date
hospital. and chronological account of patient care 0 0 0 0 0 0 0 0 0 0
27 Completeness and Legibility 0 0 0 0 0 0 0 0 0 0
28 Discharge summary contents 0 0 0 0 0 0 0 0 0 0
a a) Patient’s name, age, sex, ward, IP number, UHID number,
DOA, DOS, DOD documented
b b) ICD codification of final diagnosis, and / or procedure
c c) Documentation of investigations done with reports
d e) Documentation of medications administered during
treatment
e f) Condition of patient at the time of discharge
f g) Follow-up advice – Medications to be written in simple
format – in an understandable manner
g h) Diet advice documented in discharge summary
h i) Information regarding “when” and “how” the patient shall
seek urgent medical care
 %
n= (1) + (2) Fulfilled=(1)X
100/n
 Medical Audit : M.PALADA Month :DEC 2020
1 2 3 4 5 6 7 8 9 10
(2) No. Not
(1) No. Fulfilled (3) No. Not
No ITEM Fulfilled (no
Yes NO (No. of yes) Applicable
of Nos)

1 UHID number documented 1 1 1 1 1 1 1 1 1 1

2 Documentation of final diagnosis with ICD code on the face sheet 1 1 1 1 1 1 1 1 1 1
3 Discharge / Referral / Death – signed, named, dated and timed 1 1 1 1 1 1 1 1 1 1
by treating doctor
4 General consent signed by the Medical Officer affixed with name, 1 1 1 1 1 1 1 1 1 1
date and time.
5 General consent signed by the patient / family / attendant and 1 1 1 1 1 1 1 1 1 1
affixed with name, date and time
6 TPR chart documented in graphic format indicating of number of 1 1 1 1 1 1 1 1 1 1
in-patient
Nutritionaldays, BP, weight,
screening done byetc.
thesigned by the staff nurse
staff nurse
7 0 0 0 0 0 0 0 0 0 0
8 Documentation of pain intensity score in VDS in Nursing 0 0 0 0 0 0 0 0 0 0
assessment
Nursing care plan documented by staff nurse affixed with sign,
9 1 1 1 1 1 1 1 1 1 1
name,
Medicaldate and time
officer’s name, date and time at the beginning of Initial
10 1 1 1 1 1 1 1 1 1 1
Assessment.
11 Provisional diagnosis documented by the treating doctor 1 1 1 1 1 1 1 1 1 1
12 Documentation of treatment plan, goals and objectives by the 1 1 1 1 1 1 1 1 1 1
treating doctor
13 Dietary advice documented by the treating doctor 1 1 1 1 1 1 1 1 1 1
14 Medical prescriptions written in a comprehendible manner in 1 1 1 1 1 1 1 1 1 1
uniform location, duly signed, named, dated and timed by the
15 Error prone abbreviations used in medical prescriptions 1 1 1 1 1 1 1 1 1 1
16 Informed consents duly signed, named, dated and timed by the 1 1 1 1 1 1 1 1 1 1
patient / family / attendant with documentation of relationship
17 Lab investigations reports provided in a standardized report NA NA NA NA NA NA NA NA NA NA
format duly signed,
Documentation named,
of date dated anddate
of collection, timed by the Lab
of expiry, screening
18 NA NA NA NA NA NA NA NA NA NA
tests results, blood group and type in the blood cross matching
19 Referral
form dulynotes withnamed
signed, signature
and of the Medical
dated Officer Officer
by the Medical affixed with NA NA NA NA NA NA NA NA NA NA
name, date and time.
20 Time and signature of staff nurse documented in the medication 1 1 1 1 1 1 1 1 1 1
administration chart
21 Nurses’ report with signature of the staff nurse affixed with name 1 1 1 1 1 1 1 1 1 1
and date
22 Partograph with details signed by the staff nurse affixed with NA NA NA NA NA NA NA NA NA NA
name, date and time
23 Physiotherapy assessment and re-assessment documented, NA NA NA NA NA NA NA NA NA NA
signed, named and dated by the physiotherapist affixed with
24 Patient’s
name, datename,
and UHID
time number, IP number, age, sex, ward details, 1 1 1 1 1 1 1 1 1 1
hospital name and medical record sheet number documented on
25 Documentation
the continuationofsheet
patient transfer
of the to other
medical hospitals – details of
record NA NA NA NA NA NA NA NA NA NA
date of transfer, reason for transfer and name of the receiving
26 Up-to-date
hospital. and chronological account of patient care 0 0 0 0 0 0 0 0 0 0
27 Completeness and Legibility 1 1 1 1 1 1 1 1 1 1
28 Discharge summary contents
a a) Patient’s name, age, sex, ward, IP number, UHID number, 0 0 0 0 0 0 0 0 0 0
DOA, DOS, DOD documented
b b) ICD codification of final diagnosis, and / or procedure 0 0 0 0 0 0 0 0 0 0
c c) Documentation of investigations done with reports 0 0 0 0 0 0 0 0 0 0
d e) Documentation of medications administered during 1 1 1 1 1 1 1 1 1 1
treatment
e f) Condition of patient at the time of discharge 1 1 1 1 1 1 1 1 1 1
f g) Follow-up advice – Medications to be written in simple 1 1 1 1 1 1 1 1 1 1
format – in an understandable manner
g h) Diet advice documented in discharge summary 1 1 1 1 1 1 1 1 1 1
h i) Information regarding “when” and “how” the patient shall 1 1 1 1 1 1 1 1 1 1
seek urgent medical care
 %
n= (1) + (2) Fulfilled=(1)X
100/n
 Medical Audit : M.PALADA Month: JAN 2021
1 2 3 4 5 6 7 8 9 10
(1) No. (2) No. Not
(3) No. Not
No ITEM Fulfilled (No. Fulfilled (no
Yes NO Applicable
of yes) of Nos)

1 UHID number documented 1 1 1 1 1 1 1 1 1 1

2 Documentation of final diagnosis with ICD code on the face sheet 1 1 1 1 1 1 1 1 1 1
3 Discharge / Referral / Death – signed, named, dated and timed 1 1 1 1 1 1 1 1 1 1
by treating doctor
4 General consent signed by the Medical Officer affixed with name, 1 1 1 1 1 1 1 1 1 1
date and time.
5 General consent signed by the patient / family / attendant and 1 1 1 1 1 1 1 1 1 1
affixed with name, date and time
6 TPR chart documented in graphic format indicating of number of 1 1 1 1 1 1 1 1 1 1
in-patient
Nutritionaldays, BP, weight,
screening done byetc.
thesigned by the staff nurse
staff nurse
7 0 0 0 0 0 0 0 0 0 0
8 Documentation of pain intensity score in VDS in Nursing 0 0 0 0 0 0 0 0 0 0
assessment
Nursing care plan documented by staff nurse affixed with sign,
9 1 1 1 1 1 1 1 1 1 1
name,
Medicaldate and time
officer’s name, date and time at the beginning of Initial
10 1 1 1 1 1 1 1 1 1 1
Assessment.
11 Provisional diagnosis documented by the treating doctor 1 1 1 1 1 1 1 1 1 1
12 Documentation of treatment plan, goals and objectives by the 1 1 1 1 1 1 1 1 1 1
treating doctor
13 Dietary advice documented by the treating doctor 1 1 1 1 1 1 1 1 1 1
14 Medical prescriptions written in a comprehendible manner in 1 1 1 1 1 1 1 1 1 1
uniform location, duly signed, named, dated and timed by the
15 Error prone abbreviations used in medical prescriptions 1 1 1 1 1 1 1 1 1 1
16 Informed consents duly signed, named, dated and timed by the 1 1 1 1 1 1 1 1 1 1
patient / family / attendant with documentation of relationship
17 Lab investigations reports provided in a standardized report NA NA NA NA NA NA NA NA NA NA
format duly signed,
Documentation named,
of date dated anddate
of collection, timed by the Lab
of expiry, screening
18 NA NA NA NA NA NA NA NA NA NA
tests results, blood group and type in the blood cross matching
19 Referral
form dulynotes withnamed
signed, signature
and of the Medical
dated Officer Officer
by the Medical affixed with NA NA NA NA NA NA NA NA NA NA
name, date and time.
20 Time and signature of staff nurse documented in the medication 1 1 1 1 1 1 1 1 1 1
administration chart
21 Nurses’ report with signature of the staff nurse affixed with name 1 1 1 1 1 1 1 1 1 1
and date
22 Partograph with details signed by the staff nurse affixed with NA NA NA NA NA NA NA NA NA NA
name, date and time
23 Physiotherapy assessment and re-assessment documented, NA NA NA NA NA NA NA NA NA NA
signed, named and dated by the physiotherapist affixed with
24 Patient’s
name, datename,
and UHID
time number, IP number, age, sex, ward details, 1 1 1 1 1 1 1 1 1 1
hospital name and medical record sheet number documented on
25 Documentation
the continuationofsheet
patient transfer
of the to other
medical hospitals – details of
record NA NA NA NA NA NA NA NA NA NA
date of transfer, reason for transfer and name of the receiving
26 Up-to-date
hospital. and chronological account of patient care 0 0 0 0 0 0 0 0 0 0
27 Completeness and Legibility 1 1 1 1 1 1 1 1 1 1
28 Discharge summary contents
a a) Patient’s name, age, sex, ward, IP number, UHID number, 0 0 0 0 0 0 0 0 0 0
DOA, DOS, DOD documented
b b) ICD codification of final diagnosis, and / or procedure 0 0 0 0 0 0 0 0 0 0
c c) Documentation of investigations done with reports 0 0 0 0 0 0 0 0 0 0
d e) Documentation of medications administered during 1 1 1 1 1 1 1 1 1 1
treatment
e f) Condition of patient at the time of discharge 1 1 1 1 1 1 1 1 1 1
f g) Follow-up advice – Medications to be written in simple 1 1 1 1 1 1 1 1 1 1
format – in an understandable manner
g h) Diet advice documented in discharge summary 1 1 1 1 1 1 1 1 1 1
h i) Information regarding “when” and “how” the patient shall 1 1 1 1 1 1 1 1 1 1
seek urgent medical care
 %
n= (1) + (2) Fulfilled=(1)X
100/n
 Medical Audit : M.PALADA Month: FEB 2021
1 2 3 4 5 6 7 8 9 10
(1) No. (2) No. Not %
(3) No. Not
No ITEM Fulfilled (No. Fulfilled (no n= (1) + (2) Fulfilled=(1)X
Yes NO Applicable
of yes) of Nos) 100/n

1 UHID number documented 1 1 1 1 1 1 1 1 1 1

2 Documentation of final diagnosis with ICD code on the face sheet 1 1 1 1 1 1 1 1 1 1
3 Discharge / Referral / Death – signed, named, dated and timed 1 1 1 1 1 1 1 1 1 1
by treating doctor
4 General consent signed by the Medical Officer affixed with name, 1 1 1 1 1 1 1 1 1 1
date and time.
5 General consent signed by the patient / family / attendant and 1 1 1 1 1 1 1 1 1 1
affixed with name, date and time
6 TPR chart documented in graphic format indicating of number of 1 1 1 1 1 1 1 1 1 1
in-patient
Nutritionaldays, BP, weight,
screening done byetc.
thesigned by the staff nurse
staff nurse
7 1 1 1 1 1 1 1 1 1 1
8 Documentation of pain intensity score in VDS in Nursing 1 1 1 1 1 1 1 1 1 1
assessment
Nursing care plan documented by staff nurse affixed with sign,
9 1 1 1 1 1 1 1 1 1 1
name,
Medicaldate and time
officer’s name, date and time at the beginning of Initial
10 1 1 1 1 1 1 1 1 1 1
Assessment.
11 Provisional diagnosis documented by the treating doctor 1 1 1 1 1 1 1 1 1 1
12 Documentation of treatment plan, goals and objectives by the 1 1 1 1 1 1 1 1 1 1
treating doctor
13 Dietary advice documented by the treating doctor 1 1 1 1 1 1 1 1 1 1
14 Medical prescriptions written in a comprehendible manner in 1 1 1 1 1 1 1 1 1 1
uniform location, duly signed, named, dated and timed by the
15 Error prone abbreviations used in medical prescriptions 1 1 1 1 1 1 1 1 1 1
16 Informed consents duly signed, named, dated and timed by the 1 1 1 1 1 1 1 1 1 1
patient / family / attendant with documentation of relationship
17 Lab investigations reports provided in a standardized report
format duly signed,
Documentation named,
of date dated anddate
of collection, timed by the Lab
of expiry, screening
18
tests results, blood group and type in the blood cross matching
19 Referral
form dulynotes withnamed
signed, signature
and of the Medical
dated Officer Officer
by the Medical affixed with
name, date and time.
20 Time and signature of staff nurse documented in the medication 1 1 1 1 1 1 1 1 1 1 1
administration chart
21 Nurses’ report with signature of the staff nurse affixed with name 1 1 1 1 1 1 1 1 1 1 1
and date
22 Partograph with details signed by the staff nurse affixed with
name, date and time
23 Physiotherapy assessment and re-assessment documented,
signed, named and dated by the physiotherapist affixed with
24 Patient’s
name, datename,
and UHID
time number, IP number, age, sex, ward details, 1 1 1 1 1 1 1 1 1 1 1
hospital name and medical record sheet number documented on
25 Documentation
the continuationofsheet
patient transfer
of the to other
medical hospitals – details of
record 1 1 1 1 1 1 1 1 1 1 1
date of transfer, reason for transfer and name of the receiving
26 Up-to-date
hospital. and chronological account of patient care 1 1 1 1 1 1 1 1 1 1 1
27 Completeness and Legibility 1 1 1 1 1 1 1 1 1 1 1
28 Discharge summary contents 1 1 1 1 1 1 1 1 1 1 1
a a) Patient’s name, age, sex, ward, IP number, UHID number, 1 1 1 1 1 1 1 1 1 1 1
DOA, DOS, DOD documented
b b) ICD codification of final diagnosis, and / or procedure 1 1 1 1 1 1 1 1 1 1 1
c c) Documentation of investigations done with reports 1 1 1 1 1 1 1 1 1 1 1
d e) Documentation of medications administered during 1 1 1 1 1 1 1 1 1 1 1
treatment
e f) Condition of patient at the time of discharge 1 1 1 1 1 1 1 1 1 1 1
f g) Follow-up advice – Medications to be written in simple 1 1 1 1 1 1 1 1 1 1 1
format – in an understandable manner
g h) Diet advice documented in discharge summary 1 1 1 1 1 1 1 1 1 1 1
h i) Information regarding “when” and “how” the patient shall 1 1 1 1 1 1 1 1 1 1 1
seek urgent medical care
 Medical Audit : M.PALADA Month: MARCH 2021
1 2 3 4 5 6 7 8 9 10
(1) No. (2) No. Not %
(3) No. Not
No ITEM Fulfilled (No. Fulfilled (no n= (1) + (2) Fulfilled=(1)X
Yes NO Applicable
of yes) of Nos) 100/n

1 UHID number documented 1 1 1 1 1 1 1 1 1 1

2 Documentation of final diagnosis with ICD code on the face sheet 1 1 1 1 1 1 1 1 1 1
3 Discharge / Referral / Death – signed, named, dated and timed 1 1 1 1 1 1 1 1 1 1
by treating doctor
4 General consent signed by the Medical Officer affixed with name, 1 1 1 1 1 1 1 1 1 1
date and time.
5 General consent signed by the patient / family / attendant and 1 1 1 1 1 1 1 1 1 1
affixed with name, date and time
6 TPR chart documented in graphic format indicating of number of 1 1 1 1 1 1 1 1 1 1
in-patient
Nutritionaldays, BP, weight,
screening done byetc.
thesigned by the staff nurse
staff nurse
7 1 1 1 1 1 1 1 1 1 1
8 Documentation of pain intensity score in VDS in Nursing 1 1 1 1 1 1 1 1 1 1
assessment
Nursing care plan documented by staff nurse affixed with sign,
9 1 1 1 1 1 1 1 1 1 1
name,
Medicaldate and time
officer’s name, date and time at the beginning of Initial
10 1 1 1 1 1 1 1 1 1 1
Assessment.
11 Provisional diagnosis documented by the treating doctor 1 1 1 1 1 1 1 1 1 1
12 Documentation of treatment plan, goals and objectives by the 1 1 1 1 1 1 1 1 1 1
treating doctor
13 Dietary advice documented by the treating doctor 1 1 1 1 1 1 1 1 1 1
14 Medical prescriptions written in a comprehendible manner in 1 1 1 1 1 1 1 1 1 1
uniform location, duly signed, named, dated and timed by the
15 Error prone abbreviations used in medical prescriptions 1 1 1 1 1 1 1 1 1 1
16 Informed consents duly signed, named, dated and timed by the 1 1 1 1 1 1 1 1 1 1
patient / family / attendant with documentation of relationship
17 Lab investigations reports provided in a standardized report
format duly signed,
Documentation named,
of date dated anddate
of collection, timed by the Lab
of expiry, screening
18
tests results, blood group and type in the blood cross matching
19 Referral
form dulynotes withnamed
signed, signature
and of the Medical
dated Officer Officer
by the Medical affixed with
name, date and time.
20 Time and signature of staff nurse documented in the medication 1 1 1 1 1 1 1 1 1 1 1
administration chart
21 Nurses’ report with signature of the staff nurse affixed with name 1 1 1 1 1 1 1 1 1 1 1
and date
22 Partograph with details signed by the staff nurse affixed with
name, date and time
23 Physiotherapy assessment and re-assessment documented,
signed, named and dated by the physiotherapist affixed with
24 Patient’s
name, datename,
and UHID
time number, IP number, age, sex, ward details, 1 1 1 1 1 1 1 1 1 1 1
hospital name and medical record sheet number documented on
25 Documentation
the continuationofsheet
patient transfer
of the to other
medical hospitals – details of
record 1 1 1 1 1 1 1 1 1 1 1
date of transfer, reason for transfer and name of the receiving
26 Up-to-date
hospital. and chronological account of patient care 1 1 1 1 1 1 1 1 1 1 1
27 Completeness and Legibility 1 1 1 1 1 1 1 1 1 1 1
28 Discharge summary contents 1 1 1 1 1 1 1 1 1 1 1
a a) Patient’s name, age, sex, ward, IP number, UHID number, 1 1 1 1 1 1 1 1 1 1 1
DOA, DOS, DOD documented
b b) ICD codification of final diagnosis, and / or procedure 1 1 1 1 1 1 1 1 1 1 1
c c) Documentation of investigations done with reports 1 1 1 1 1 1 1 1 1 1 1
d e) Documentation of medications administered during 1 1 1 1 1 1 1 1 1 1 1
treatment
e f) Condition of patient at the time of discharge 1 1 1 1 1 1 1 1 1 1 1
f g) Follow-up advice – Medications to be written in simple 1 1 1 1 1 1 1 1 1 1 1
format – in an understandable manner
g h) Diet advice documented in discharge summary 1 1 1 1 1 1 1 1 1 1 1
h i) Information regarding “when” and “how” the patient shall 1 1 1 1 1 1 1 1 1 1 1
seek urgent medical care
 Medical Audit : M.PALADA Month: APRIL 2021
1 2 3 4 5 6 7 8 9 10
(1) No. (2) No. Not %
(3) No. Not
No ITEM Fulfilled (No. Fulfilled (no n= (1) + (2) Fulfilled=(1)X
Yes NO Applicable
of yes) of Nos) 100/n

1 UHID number documented 1 1 1 1 1 1 1 1 1 1

2 Documentation of final diagnosis with ICD code on the face sheet 1 1 1 1 1 1 1 1 1 1
3 Discharge / Referral / Death – signed, named, dated and timed 1 1 1 1 1 1 1 1 1 1
by treating doctor
4 General consent signed by the Medical Officer affixed with name, 1 1 1 1 1 1 1 1 1 1
date and time.
5 General consent signed by the patient / family / attendant and 1 1 1 1 1 1 1 1 1 1
affixed with name, date and time
6 TPR chart documented in graphic format indicating of number of 1 1 1 1 1 1 1 1 1 1
in-patient
Nutritionaldays, BP, weight,
screening done byetc.
thesigned by the staff nurse
staff nurse
7 1 1 1 1 1 1 1 1 1 1
8 Documentation of pain intensity score in VDS in Nursing 1 1 1 1 1 1 1 1 1 1
assessment
Nursing care plan documented by staff nurse affixed with sign,
9 1 1 1 1 1 1 1 1 1 1
name,
Medicaldate and time
officer’s name, date and time at the beginning of Initial
10 1 1 1 1 1 1 1 1 1 1
Assessment.
11 Provisional diagnosis documented by the treating doctor 1 1 1 1 1 1 1 1 1 1
12 Documentation of treatment plan, goals and objectives by the 1 1 1 1 1 1 1 1 1 1
treating doctor
13 Dietary advice documented by the treating doctor 1 1 1 1 1 1 1 1 1 1
14 Medical prescriptions written in a comprehendible manner in 1 1 1 1 1 1 1 1 1 1
uniform location, duly signed, named, dated and timed by the
15 Error prone abbreviations used in medical prescriptions 1 1 1 1 1 1 1 1 1 1
16 Informed consents duly signed, named, dated and timed by the 1 1 1 1 1 1 1 1 1 1
patient / family / attendant with documentation of relationship
17 Lab investigations reports provided in a standardized report
format duly signed,
Documentation named,
of date dated anddate
of collection, timed by the Lab
of expiry, screening
18
tests results, blood group and type in the blood cross matching
19 Referral
form dulynotes withnamed
signed, signature
and of the Medical
dated Officer Officer
by the Medical affixed with
name, date and time.
20 Time and signature of staff nurse documented in the medication 1 1 1 1 1 1 1 1 1 1 1
administration chart
21 Nurses’ report with signature of the staff nurse affixed with name 1 1 1 1 1 1 1 1 1 1 1
and date
22 Partograph with details signed by the staff nurse affixed with
name, date and time
23 Physiotherapy assessment and re-assessment documented,
signed, named and dated by the physiotherapist affixed with
24 Patient’s
name, datename,
and UHID
time number, IP number, age, sex, ward details, 1 1 1 1 1 1 1 1 1 1 1
hospital name and medical record sheet number documented on
25 Documentation
the continuationofsheet
patient transfer
of the to other
medical hospitals – details of
record 1 1 1 1 1 1 1 1 1 1 1
date of transfer, reason for transfer and name of the receiving
26 Up-to-date
hospital. and chronological account of patient care 1 1 1 1 1 1 1 1 1 1 1
27 Completeness and Legibility 1 1 1 1 1 1 1 1 1 1 1
28 Discharge summary contents 1 1 1 1 1 1 1 1 1 1 1
a a) Patient’s name, age, sex, ward, IP number, UHID number, 1 1 1 1 1 1 1 1 1 1 1
DOA, DOS, DOD documented
b b) ICD codification of final diagnosis, and / or procedure 1 1 1 1 1 1 1 1 1 1 1
c c) Documentation of investigations done with reports 1 1 1 1 1 1 1 1 1 1 1
d e) Documentation of medications administered during 1 1 1 1 1 1 1 1 1 1 1
treatment
e f) Condition of patient at the time of discharge 1 1 1 1 1 1 1 1 1 1 1
f g) Follow-up advice – Medications to be written in simple 1 1 1 1 1 1 1 1 1 1 1
format – in an understandable manner
g h) Diet advice documented in discharge summary 1 1 1 1 1 1 1 1 1 1 1
h i) Information regarding “when” and “how” the patient shall 1 1 1 1 1 1 1 1 1 1 1
seek urgent medical care
 Medical Audit : M.PALADA Month: MAY 2021
1 2 3 4 5 6 7 8 9 10
(1) No. (2) No. Not %
(3) No. Not
No ITEM Fulfilled (No. Fulfilled (no n= (1) + (2) Fulfilled=(1)X
Yes NO Applicable
of yes) of Nos) 100/n

1 UHID number documented 1 1 1 1 1 1 1 1 1 1

2 Documentation of final diagnosis with ICD code on the face sheet 1 1 1 1 1 1 1 1 1 1
3 Discharge / Referral / Death – signed, named, dated and timed 1 1 1 1 1 1 1 1 1 1
by treating doctor
4 General consent signed by the Medical Officer affixed with name, 1 1 1 1 1 1 1 1 1 1
date and time.
5 General consent signed by the patient / family / attendant and 1 1 1 1 1 1 1 1 1 1
affixed with name, date and time
6 TPR chart documented in graphic format indicating of number of 1 1 1 1 1 1 1 1 1 1
in-patient
Nutritionaldays, BP, weight,
screening done byetc.
thesigned by the staff nurse
staff nurse
7 1 1 1 1 1 1 1 1 1 1
8 Documentation of pain intensity score in VDS in Nursing 1 1 1 1 1 1 1 1 1 1
assessment
Nursing care plan documented by staff nurse affixed with sign,
9 1 1 1 1 1 1 1 1 1 1
name,
Medicaldate and time
officer’s name, date and time at the beginning of Initial
10 1 1 1 1 1 1 1 1 1 1
Assessment.
11 Provisional diagnosis documented by the treating doctor 1 1 1 1 1 1 1 1 1 1
12 Documentation of treatment plan, goals and objectives by the 1 1 1 1 1 1 1 1 1 1
treating doctor
13 Dietary advice documented by the treating doctor 1 1 1 1 1 1 1 1 1 1
14 Medical prescriptions written in a comprehendible manner in 1 1 1 1 1 1 1 1 1 1
uniform location, duly signed, named, dated and timed by the
15 Error prone abbreviations used in medical prescriptions 1 1 1 1 1 1 1 1 1 1
16 Informed consents duly signed, named, dated and timed by the 1 1 1 1 1 1 1 1 1 1
patient / family / attendant with documentation of relationship
17 Lab investigations reports provided in a standardized report
format duly signed,
Documentation named,
of date dated anddate
of collection, timed by the Lab
of expiry, screening
18
tests results, blood group and type in the blood cross matching
19 Referral
form dulynotes withnamed
signed, signature
and of the Medical
dated Officer Officer
by the Medical affixed with
name, date and time.
20 Time and signature of staff nurse documented in the medication 1 1 1 1 1 1 1 1 1 1 1
administration chart
21 Nurses’ report with signature of the staff nurse affixed with name 1 1 1 1 1 1 1 1 1 1 1
and date
22 Partograph with details signed by the staff nurse affixed with
name, date and time
23 Physiotherapy assessment and re-assessment documented,
signed, named and dated by the physiotherapist affixed with
24 Patient’s
name, datename,
and UHID
time number, IP number, age, sex, ward details, 1 1 1 1 1 1 1 1 1 1 1
hospital name and medical record sheet number documented on
25 Documentation
the continuationofsheet
patient transfer
of the to other
medical hospitals – details of
record 1 1 1 1 1 1 1 1 1 1 1
date of transfer, reason for transfer and name of the receiving
26 Up-to-date
hospital. and chronological account of patient care 1 1 1 1 1 1 1 1 1 1 1
27 Completeness and Legibility 1 1 1 1 1 1 1 1 1 1 1
28 Discharge summary contents 1 1 1 1 1 1 1 1 1 1 1
a a) Patient’s name, age, sex, ward, IP number, UHID number, 1 1 1 1 1 1 1 1 1 1 1
DOA, DOS, DOD documented
b b) ICD codification of final diagnosis, and / or procedure 1 1 1 1 1 1 1 1 1 1 1
c c) Documentation of investigations done with reports 1 1 1 1 1 1 1 1 1 1 1
d e) Documentation of medications administered during 1 1 1 1 1 1 1 1 1 1 1
treatment
e f) Condition of patient at the time of discharge 1 1 1 1 1 1 1 1 1 1 1
f g) Follow-up advice – Medications to be written in simple 1 1 1 1 1 1 1 1 1 1 1
format – in an understandable manner
g h) Diet advice documented in discharge summary 1 1 1 1 1 1 1 1 1 1 1
h i) Information regarding “when” and “how” the patient shall 1 1 1 1 1 1 1 1 1 1 1
seek urgent medical care
 Medical Audit : M.PALADA Month: JUNE 2021
1 2 3 4 5 6 7 8 9 10
(1) No. (2) No. Not %
(3) No. Not
No ITEM Fulfilled (No. Fulfilled (no n= (1) + (2) Fulfilled=(1)X
Yes NO Applicable
of yes) of Nos) 100/n

1 UHID number documented 1 1 1 1 1 1 1 1 1 1

2 Documentation of final diagnosis with ICD code on the face sheet 1 1 1 1 1 1 1 1 1 1
3 Discharge / Referral / Death – signed, named, dated and timed 1 1 1 1 1 1 1 1 1 1
by treating doctor
4 General consent signed by the Medical Officer affixed with name, 1 1 1 1 1 1 1 1 1 1
date and time.
5 General consent signed by the patient / family / attendant and 1 1 1 1 1 1 1 1 1 1
affixed with name, date and time
6 TPR chart documented in graphic format indicating of number of 1 1 1 1 1 1 1 1 1 1
in-patient
Nutritionaldays, BP, weight,
screening done byetc.
thesigned by the staff nurse
staff nurse
7 1 1 1 1 1 1 1 1 1 1
8 Documentation of pain intensity score in VDS in Nursing 1 1 1 1 1 1 1 1 1 1
assessment
Nursing care plan documented by staff nurse affixed with sign,
9 1 1 1 1 1 1 1 1 1 1
name,
Medicaldate and time
officer’s name, date and time at the beginning of Initial
10 1 1 1 1 1 1 1 1 1 1
Assessment.
11 Provisional diagnosis documented by the treating doctor 1 1 1 1 1 1 1 1 1 1
12 Documentation of treatment plan, goals and objectives by the 1 1 1 1 1 1 1 1 1 1
treating doctor
13 Dietary advice documented by the treating doctor 1 1 1 1 1 1 1 1 1 1
14 Medical prescriptions written in a comprehendible manner in 1 1 1 1 1 1 1 1 1 1
uniform location, duly signed, named, dated and timed by the
15 Error prone abbreviations used in medical prescriptions 1 1 1 1 1 1 1 1 1 1
16 Informed consents duly signed, named, dated and timed by the 1 1 1 1 1 1 1 1 1 1
patient / family / attendant with documentation of relationship
17 Lab investigations reports provided in a standardized report
format duly signed,
Documentation named,
of date dated anddate
of collection, timed by the Lab
of expiry, screening
18
tests results, blood group and type in the blood cross matching
19 Referral
form dulynotes withnamed
signed, signature
and of the Medical
dated Officer Officer
by the Medical affixed with
name, date and time.
20 Time and signature of staff nurse documented in the medication 1 1 1 1 1 1 1 1 1 1 1
administration chart
21 Nurses’ report with signature of the staff nurse affixed with name 1 1 1 1 1 1 1 1 1 1 1
and date
22 Partograph with details signed by the staff nurse affixed with
name, date and time
23 Physiotherapy assessment and re-assessment documented,
signed, named and dated by the physiotherapist affixed with
24 Patient’s
name, datename,
and UHID
time number, IP number, age, sex, ward details, 1 1 1 1 1 1 1 1 1 1 1
hospital name and medical record sheet number documented on
25 Documentation
the continuationofsheet
patient transfer
of the to other
medical hospitals – details of
record 1 1 1 1 1 1 1 1 1 1 1
date of transfer, reason for transfer and name of the receiving
26 Up-to-date
hospital. and chronological account of patient care 1 1 1 1 1 1 1 1 1 1 1
27 Completeness and Legibility 1 1 1 1 1 1 1 1 1 1 1
28 Discharge summary contents 1 1 1 1 1 1 1 1 1 1 1
a a) Patient’s name, age, sex, ward, IP number, UHID number, 1 1 1 1 1 1 1 1 1 1 1
DOA, DOS, DOD documented
b b) ICD codification of final diagnosis, and / or procedure 1 1 1 1 1 1 1 1 1 1 1
c c) Documentation of investigations done with reports 1 1 1 1 1 1 1 1 1 1 1
d e) Documentation of medications administered during 1 1 1 1 1 1 1 1 1 1 1
treatment
e f) Condition of patient at the time of discharge 1 1 1 1 1 1 1 1 1 1 1
f g) Follow-up advice – Medications to be written in simple 1 1 1 1 1 1 1 1 1 1 1
format – in an understandable manner
g h) Diet advice documented in discharge summary 1 1 1 1 1 1 1 1 1 1 1
h i) Information regarding “when” and “how” the patient shall 1 1 1 1 1 1 1 1 1 1 1
seek urgent medical care
 Medical Audit : M.PALADA Month: JULY 2021
1 2 3 4 5 6 7 8 9 10
(1) No. (2) No. Not %
(3) No. Not
No ITEM Fulfilled (No. Fulfilled (no n= (1) + (2) Fulfilled=(1)X
Yes NO Applicable
of yes) of Nos) 100/n

1 UHID number documented 1 1 1 1 1 1 1 1 1 1

2 Documentation of final diagnosis with ICD code on the face sheet 1 1 1 1 1 1 1 1 1 1
3 Discharge / Referral / Death – signed, named, dated and timed 1 1 1 1 1 1 1 1 1 1
by treating doctor
4 General consent signed by the Medical Officer affixed with name, 1 1 1 1 1 1 1 1 1 1
date and time.
5 General consent signed by the patient / family / attendant and 1 1 1 1 1 1 1 1 1 1
affixed with name, date and time
6 TPR chart documented in graphic format indicating of number of 1 1 1 1 1 1 1 1 1 1
in-patient
Nutritionaldays, BP, weight,
screening done byetc.
thesigned by the staff nurse
staff nurse
7 1 1 1 1 1 1 1 1 1 1
8 Documentation of pain intensity score in VDS in Nursing 1 1 1 1 1 1 1 1 1 1
assessment
Nursing care plan documented by staff nurse affixed with sign,
9 1 1 1 1 1 1 1 1 1 1
name,
Medicaldate and time
officer’s name, date and time at the beginning of Initial
10 1 1 1 1 1 1 1 1 1 1
Assessment.
11 Provisional diagnosis documented by the treating doctor 1 1 1 1 1 1 1 1 1 1
12 Documentation of treatment plan, goals and objectives by the 1 1 1 1 1 1 1 1 1 1
treating doctor
13 Dietary advice documented by the treating doctor 1 1 1 1 1 1 1 1 1 1
14 Medical prescriptions written in a comprehendible manner in 1 1 1 1 1 1 1 1 1 1
uniform location, duly signed, named, dated and timed by the
15 Error prone abbreviations used in medical prescriptions 1 1 1 1 1 1 1 1 1 1
16 Informed consents duly signed, named, dated and timed by the 1 1 1 1 1 1 1 1 1 1
patient / family / attendant with documentation of relationship
17 Lab investigations reports provided in a standardized report
format duly signed,
Documentation named,
of date dated anddate
of collection, timed by the Lab
of expiry, screening
18
tests results, blood group and type in the blood cross matching
19 Referral
form dulynotes withnamed
signed, signature
and of the Medical
dated Officer Officer
by the Medical affixed with
name, date and time.
20 Time and signature of staff nurse documented in the medication 1 1 1 1 1 1 1 1 1 1 1
administration chart
21 Nurses’ report with signature of the staff nurse affixed with name 1 1 1 1 1 1 1 1 1 1 1
and date
22 Partograph with details signed by the staff nurse affixed with
name, date and time
23 Physiotherapy assessment and re-assessment documented,
signed, named and dated by the physiotherapist affixed with
24 Patient’s
name, datename,
and UHID
time number, IP number, age, sex, ward details, 1 1 1 1 1 1 1 1 1 1 1
hospital name and medical record sheet number documented on
25 Documentation
the continuationofsheet
patient transfer
of the to other
medical hospitals – details of
record 1 1 1 1 1 1 1 1 1 1 1
date of transfer, reason for transfer and name of the receiving
26 Up-to-date
hospital. and chronological account of patient care 1 1 1 1 1 1 1 1 1 1 1
27 Completeness and Legibility 1 1 1 1 1 1 1 1 1 1 1
28 Discharge summary contents 1 1 1 1 1 1 1 1 1 1 1
a a) Patient’s name, age, sex, ward, IP number, UHID number, 1 1 1 1 1 1 1 1 1 1 1
DOA, DOS, DOD documented
b b) ICD codification of final diagnosis, and / or procedure 1 1 1 1 1 1 1 1 1 1 1
c c) Documentation of investigations done with reports 1 1 1 1 1 1 1 1 1 1 1
d e) Documentation of medications administered during 1 1 1 1 1 1 1 1 1 1 1
treatment
e f) Condition of patient at the time of discharge 1 1 1 1 1 1 1 1 1 1 1
f g) Follow-up advice – Medications to be written in simple 1 1 1 1 1 1 1 1 1 1 1
format – in an understandable manner
g h) Diet advice documented in discharge summary 1 1 1 1 1 1 1 1 1 1 1
h i) Information regarding “when” and “how” the patient shall 1 1 1 1 1 1 1 1 1 1 1
seek urgent medical care
 Medical Audit : M.PALADA Month: AUG 2021
1 2 3 4 5 6 7 8 9 10
(1) No. (2) No. Not %
(3) No. Not
No ITEM Fulfilled (No. Fulfilled (no n= (1) + (2) Fulfilled=(1)X
Yes NO Applicable
of yes) of Nos) 100/n

1 UHID number documented YES 1 1 1 1 1 1 1 1 1 1

2 Documentation of final diagnosis with ICD code on the face sheet YES 1 1 1 1 1 1 1 1 1 1
3 Discharge / Referral / Death – signed, named, dated and timed YES 1 1 1 1 1 1 1 1 1 1
by treating doctor
4 General consent signed by the Medical Officer affixed with name, 1 1 1 1 1 1 1 1 1 1
date and time.
5 General consent signed by the patient / family / attendant and 1 1 1 1 1 1 1 1 1 1
affixed with name, date and time
6 TPR chart documented in graphic format indicating of number of 1 1 1 1 1 1 1 1 1 1
in-patient
Nutritionaldays, BP, weight,
screening done byetc.
thesigned by the staff nurse
staff nurse
7 1 1 1 1 1 1 1 1 1 1
8 Documentation of pain intensity score in VDS in Nursing 1 1 1 1 1 1 1 1 1 1
assessment
Nursing care plan documented by staff nurse affixed with sign,
9 1 1 1 1 1 1 1 1 1 1
name,
Medicaldate and time
officer’s name, date and time at the beginning of Initial
10 1 1 1 1 1 1 1 1 1 1
Assessment.
11 Provisional diagnosis documented by the treating doctor 1 1 1 1 1 1 1 1 1 1
12 Documentation of treatment plan, goals and objectives by the 1 1 1 1 1 1 1 1 1 1
treating doctor
13 Dietary advice documented by the treating doctor 1 1 1 1 1 1 1 1 1 1
14 Medical prescriptions written in a comprehendible manner in 1 1 1 1 1 1 1 1 1 1
uniform location, duly signed, named, dated and timed by the
15 Error prone abbreviations used in medical prescriptions 1 1 1 1 1 1 1 1 1 1
16 Informed consents duly signed, named, dated and timed by the 1 1 1 1 1 1 1 1 1 1
patient / family / attendant with documentation of relationship
17 Lab investigations reports provided in a standardized report
format duly signed,
Documentation named,
of date dated anddate
of collection, timed by the Lab
of expiry, screening
18
tests results, blood group and type in the blood cross matching
19 Referral
form dulynotes withnamed
signed, signature
and of the Medical
dated Officer Officer
by the Medical affixed with
name, date and time.
20 Time and signature of staff nurse documented in the medication 1 1 1 1 1 1 1 1 1 1 1
administration chart
21 Nurses’ report with signature of the staff nurse affixed with name 1 1 1 1 1 1 1 1 1 1 1
and date
22 Partograph with details signed by the staff nurse affixed with YES
name, date and time
23 Physiotherapy assessment and re-assessment documented,
signed, named and dated by the physiotherapist affixed with
24 Patient’s
name, datename,
and UHID
time number, IP number, age, sex, ward details, 1 1 1 1 1 1 1 1 1 1 1
hospital name and medical record sheet number documented on
25 Documentation
the continuationofsheet
patient transfer
of the to other
medical hospitals – details of
record 1 1 1 1 1 1 1 1 1 1 1
date of transfer, reason for transfer and name of the receiving
26 Up-to-date
hospital. and chronological account of patient care 1 1 1 1 1 1 1 1 1 1 1
27 Completeness and Legibility 1 1 1 1 1 1 1 1 1 1 1
28 Discharge summary contents 1 1 1 1 1 1 1 1 1 1 1
a a) Patient’s name, age, sex, ward, IP number, UHID number, 1 1 1 1 1 1 1 1 1 1 1
DOA, DOS, DOD documented
b b) ICD codification of final diagnosis, and / or procedure 1 1 1 1 1 1 1 1 1 1 1
c c) Documentation of investigations done with reports 1 1 1 1 1 1 1 1 1 1 1
d e) Documentation of medications administered during 1 1 1 1 1 1 1 1 1 1 1
treatment
e f) Condition of patient at the time of discharge 1 1 1 1 1 1 1 1 1 1 1
f g) Follow-up advice – Medications to be written in simple 1 1 1 1 1 1 1 1 1 1 1
format – in an understandable manner
g h) Diet advice documented in discharge summary 1 1 1 1 1 1 1 1 1 1 1
h i) Information regarding “when” and “how” the patient shall 1 1 1 1 1 1 1 1 1 1 1
seek urgent medical care