EMERGING ISSUES OF THE INPATIENTS’ MEDICAL RECORDS AUDIT AT

J.R. BORJA GENERAL HOSPITAL

A Capstone Project
Presented to the Faculty of the
School of Graduate and Professional Studies
PHINMA Cagayan de Oro College
Carmen, Cagayan de Oro City

In Partial Fulfilment
of The Requirements for the Degree
MASTER OF GOVERNMENT MANAGEMENT

MICHAEL C. IYOY

November 2023
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CERTIFICATE OF ORAL PRESENTATION

This Capstone Project titled, “EMERGING ISSUES OF THE INPATIENTS’

MEDICAL RECORDS AUDIT AT J.R. BORJA GENERAL HOSPITAL”,
prepared and submitted by MICHAEL C. IYOY, presented on November 25,
2023, in partial fulfillment of the subject requirement of MGS 127 for the Degree
of Master in Government Management.

MANUELITO T. DABALOS, PhD

Course Professor

________________________________________________________________

PANEL OF EXAMINERS

Approved by the Committee on Oral Examination with a rating of ____________.

BRAZIEL L. ONGCACHUY, PhD

Chairperson

MARY CRIS P. LIGAN, RGC RANDY KENTH T. RAFISURA, CFMP, MBA

Member Member

________________________________________________________________

Accepted and approved in partial fulfillment of the requirements for the

degree of Master in Government Management.

BRAZIEL L. ONGCACHUY, PhD

Dean
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ABSTRACT

The medical record is the most important hospital document available to

communicate a patient’s status and progress in therapy. This study aims to

address issues of the inpatient medical record audit to improve the

documentation processes which lead to efficiency in health care delivery,

documentation processes, and financial health of the hospital. A grounded

theory design was used in this study conducted by interviews using

questionnaires. J.R. Borja General Hospital Nurse supervisors are mainly the

respondents of this study who carried out the audit of the inpatient medical

record/chart before the patients were about to be discharged from admission.

This study took place at the J.R. Borja General Hospital, a Local Government

Unit healthcare institution. The following were the usual mistakes and

discrepancies collected as samples during the interview, Missing Documentation,

Incorrect Data Entry, Outdated Information, Inconsistent Coding, and Unresolved

Discrepancies. Results of the interview revealed, for the most part, records are

complete, and compliant with necessary regulations. However, a few areas were

identified for improvement, particularly in ensuring consistent recording of the

medical record of the patient. The recommendation to address deficiencies and

improve the quality of medical records is the revision of the checklist, the creation

of the deficiency slip, and the conducting of training programs.

Keywords: Hospital Document, Documentation Processes, Completeness and

Compliance.

ACKNOWLEDGEMENT
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First and foremost, praises and thanks to God Almighty, for His showered

blessings throughout my research work to complete the study successfully.

I would like to express my deep and sincere gratitude to our research

instructor, Manuelito T. Dabalos, Ph.D., Professor, School of Graduate &

Professional Studies, COC PHINMA Education Network, Carmen, Cagayan de

Oro City, for allowing me to do research and for his invaluable guidance

throughout this study. His dynamism, vision, sincerity, and motivation have

deeply inspired me.

I am extremely grateful to my former groupmates in other research subject

for their love and prayers for supporting me in this endeavor. I am also thankful to

my family, friends, and colleagues for their love, understanding, prayers, and

continuing support.

DEDICATION
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This research paper is dedicated to the Nursing Service staff of J.R. Borja

General Hospital who gave their utmost support, and never-ending inspiration

throughout the study. They are the ones who provide the ideas that are needed

in the making of this study. It is also dedicated to the Hospital Information

Management Department and to the Research and Training Office, the people

behind in making this research possible through their guidance. I look up and

dedicate this study to our Almighty God who gave me the strength, knowledge,

wisdom and protection to continue and be positive in this study.

TABLE OF CONTENTS

Cover/ Title Page i

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Completion Certificate ii

Abstract iii

Acknowledgment iv

Dedication v

Table of Contents vi

Introduction 1

Background of the study 2

Related Literature and Studies 2

Research Framework 10

Research Problems 11

Significance of the study 11

Methodology 13

Research Design and Instrument 13

Respondents and Settings 13

Data Gathering Procedure 15

Results and Discussion 16

Findings 21

Conclusion 22

Recommendations 23

Recommended Interventions Plan/Program 24

References 26

Appendices

A. Letter Request to Conduct the Study 27

B. Interview Guide 28
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C. Present Checklist 29

D. Documentation 30

E. Certificate of Editing 31

Curriculum Vitae 32
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INTRODUCTION

Background of the study

The medical record is the most important hospital document available to

communicate a patient’s status and progress in therapy. It is also important in

defending against or preventing legal actions. The audit of patients' medical

records is a critical component of healthcare quality assurance, patient safety,

and compliance with regulatory standards. This research paper investigates the

emerging issues in the audit of patients' medical records, shedding light on

challenges and proposing strategies to address them effectively. A medical

records audit is essentially a chart review that is used to determine what is being

done right and what needs to be improved. The study aims to address issues in

the inpatient medical record audit to improve the documentation processes which

lead to efficiency in health care delivery, documentation processes, and financial

health of the hospital.

Medical records are compiled from various sources and departments.

Discrepancies arise due to the involvement of multiple staff concerned in the

audit. Since the ratio of nurses to patients in a public hospital is below the

standard, occasionally, omissions take place due to emergencies or unexpected

situations that require immediate attention. Signatures are missing due to

oversight or administrative errors. Some documents may be missing or lack

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specific details and entries, or even lack signatures. Gathering such will take

some time, and

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procedures are not accurately recorded. This might be due to the complexities of

patient care or simultaneous occurrences that impact documentation. Despite

the checklist, some documents are missing, and inconsistencies between

different sections of the medical record of the patient. We continuously work on

improving communication among staff to ensure accurate and consistent

documentation.

The purpose of JRBGH staff doing the inpatient medical record audit, a

sort of quality assurance activity, is to determine where JRBGH stands

concerning compliance and standards by conducting formal evaluations and

assessments of our medical records.

Related Literature and Studies

Gasoma E.B.Y., (2022) conducted a study on the Retrospective audit in

documentation practice in surgical inpatient records, a two cycles audit. Good

record keeping is essential to delivering safe and efficient patient care. Regular

clinical audits are necessary to guarantee that strict record-keeping guidelines

are followed. The documentation in the surgical inpatient records was audited

and re-audited as part of a retrospective, descriptive research to determine if it

complies with the hospital's declared policy. The main goals of the audit study

were to assess the hospital's current documentation procedure and think about

ways to make current practice better. Standard hospital guidelines served as the

basis for the creation of an interactive form that was used to audit the criteria.
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The primary source of the data was a retrospective study of 120 case files.

The accuracy and completeness of the documentation in each section of the

records was assessed. The information was gathered, examined, and given to

the clinical governance. These results were included into our documentation

process so that all surgical staff members receive guidance on what

documentation is needed and how to complete it. Once more, prospective data

collection was done to finish the audit cycle.

Over 35 of the 37 pertinent audit standards saw a rise in compliance.

During the re-audit cycle, no standard or criterion's compliance decreased.

Compliance has increased across all audit criteria by an average of 32% since

the first audit cycle, indicating that some of the work completed after the first

cycle has had a notable impact. Medical practice has to view record-keeping as

essential; recent documentation work shows that audits can influence the caliber

of clinical records when carried out correctly. The audit process itself may raise

awareness of the need to change practices. Developing practice requires

dissemination of findings, training, education, and local action planning, among

other things.

Nurlu, D., & Raoof, A., (2023) conducted research titled “Inpatient Ward

Review Documentation Audit”. Maintaining accurate medical records is crucial to

the ongoing treatment of patients. This audit sought to compare records from the

first and second cycles of the audit in order to assess the quality of ward review

documentation in seven psychiatry wards of Essex Partnership University NHS

Foundation Trust, identify areas for improvement, and suggest strategies to

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improve record keeping. In the first and second cycles of the audit, ten patients

were chosen at random from each of the seven wards, for a total of seventy

patients. Data were gathered in the 1st cycle between 06-07-2021 and 22-07-

2021, and in the 2nd cycle between 16-10-2022 and 07-11-2022. Random

samples were chosen from patients who had recently been released or were

inpatients.

The first, middle, and last ward reviews provided the data. Data were

gathered from the patient's initial evaluation, the most recent ward review, and

one of the reviews in between if they were an inpatient at the time of the data

collection. Patients who didn't fit this requirement were turned away. A number of

solutions were suggested to enhance record keeping based on the first cycle

results. The results of the second cycle were utilized to assess their efficacy after

a quarter of a century. The findings show that there is room for considerable

improvement in record keeping: most questions fell short of the 80% completion

threshold that was deemed "satisfactory" in earlier audits. Nine questions in the

second cycle received a "satisfactory" completion rate.

These were required, automated queries that were necessary for

providing emergency patient care. The ‘average’ completion percentage for 7

questions was higher than 45%. The completion rates of the next seventeen

questions and sub questions were ‘low’ because the ‘responsible clinician’

question was automated, its percentage of answers improved from 23.3% to

99.5% according to an analysis of cycle fluctuations. The completion rate of four

additional questions or sub-questions increased significantly between the first

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and second cycles. However, it has been tough to track down and our strategies'

effectiveness during the audit period has shown to be limited. The improvement

of medical records in the psychiatry wards of Essex Partnership University NHS

Foundation Trust warrants more attention, it might be determined. Enforcing

mandatory or auto-complete questions is the best way to ensure high ward

review documentation rates. To prove the efficacy of additional tactics, such as

teaching junior doctors in ward introduction and posting awareness posters, more

study is required.

Casuriaga, A., Giachetto, G., Gutiérrez, S., Martínez, V., Garcı́A, A. M.,

Martínez, F., De Olivera, N., & Boulay, M. (2018) conducted a study on medical

audits involve critical and systematic analysis of the medical care process,

diagnostic and therapeutic procedures, the use of resources and the results

obtained. Systems for auditing give tools for ongoing quality improvement. Its

objective is to evaluate the quality of children's hospitalized medical records

(HMR). HMR cross-sectional research of kids who were released from a

reference hospital center's moderate care units between January 1 and

December 31, 2015. Patients' personal information, grids, growth curves,

socioeconomic background, admissions, evolution, prescriptions, transcriptions,

diagnosis at discharge, and discharge reports were among the variables that

were examined. Three groups were created and it requires a score of at least

80%, 60-79% acceptable, and less than 60% is insufficient. Age, length of

hospital stays, diagnosis at discharge, and time of year were used to evaluate

the quality of HMR. An 80% power, 5% accuracy, and 50% predicted error
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prevalence were achieved using random sampling (N = 385). P less than 0.05

was deemed significant. 52% (202) of the 385 HMRs that were studied were

boys, with a median age of 3 months. Of those, 17% were adequate, 49.6%

good, and 33.4% deficient.

When comparing children under one year old (21,5% vs.14%) with

hospitalization durations of less than or equal to three days (21% vs.11%),

adequate HMRs were more common (p<0.05). Winter had a higher percentage

of inadequate HMRs (43% vs. 29%, p<0.05). To support the analysis of these

results, a qualitative analysis is required. To further the development of electronic

records as a tool to enhance clinical management systems, it is critical to put in

place an ongoing HMR auditing system.

E. Azzolini and G. Furia et.al (2019) conducted a study on the Quality

improvement of medical records through internal auditing. The purpose of their

study was to evaluate the effectiveness of internal auditing as a means of raising

the standard of medical records in hospital environments. A teaching hospital of

the third level hosted the program. Using a random sample technique, two

retrospective evaluations of the quality of medical records were conducted by

trained ad hoc evaluation teams. A 48-item evaluation grid with nine domains—

General, Patient Medical History and Physical Examination, Daily Clinical

Progress Notes, Daily Nursing Progress Notes, Drug Therapy Chart, Pain Chart,

Discharge Summary, Surgery Register, and Informed Consent—was used to

conduct the quality assessment.

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Following the initial review of 1,460 medical records, a departmental audit

procedure was established. Following the 1.402 medical records' internal audit, a

second examination was conducted. According to the second analysis, there

has been a considerable improvement in quality in every component of the

medical chart, with all scores rising above 50%. Every area of the medical

records where discrepancies between the first and second analysis were

discovered is noteworthy. To sum up, internal audits are essential to the

organization's goal-achieving, clinical care quality assessment, and preservation

of superior professional performance. They are not merely measurement

exercises.

Also, Sylvia A. Delosa and Raul A. Delosa Jr. (2020) conducted research

in a tertiary hospital. The purpose of their study is to assess how well the

Cotabato Regional Medical Center's health information management department

implemented the records management system. They employed a quantitative-

qualitative approach to collect data from the one hundred respondents, who were

clients and staff members of CRMC. The mean was employed in the study's

statistical analysis of the collected data. The study's conclusions demonstrated

the breadth of the services offered, the filing and processing methods followed,

and the records management policies and procedures. There were a lot of

human resources seminars, training sessions, and facility and resource

upgrades. A very wide range of quality service outcomes, including information

retrieval, record life cycle preservation, and timely and accurate quality service,

were attained.
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Miscommunication and occasional inevitable delays resulting from

technological issues were among the frequent minor issues experienced.

According to the informants' descriptions of common interventions, they

frequently hold planning sessions and meetings to discuss issues that arise. The

investigation comes to the conclusion that Cotabato Regional Medical Center's

records department effectively offers its consumers high-quality services. The

facilities and equipment offered allowed for the timely and accurate delivery of

records as well as the well-maintained preservation of papers. Similarly,

seminars and training were offered to enhance staff competency, which

contributes to raising the department's service quality standards. In general, the

study advises staff members to continue and step up their adherence to

standards and procedures for records management systems.

A retrospective descriptive analysis of the data in medical records

regarding the communication of treatment limitations to patients' families who

come from a variety of cultural backgrounds. Care planning and decision-making

depend on doctors and patient families communicating about treatment limitation

practices. When discussing therapy restrictions with patients and family members

from culturally diverse backgrounds, extra considerations need to be made. This

study set out to investigate the communication of treatment constraints to

patients' families in critical care who come from a variety of cultural backgrounds.

A retrospective audit of medical records was used to conduct descriptive

research. Patients' medical records from four Melbourne, Australia, intensive

care units who passed away in 2018 were gathered. Progress note entries and
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descriptive and inferential statistics are used to present the data (Brooks, L.,

Manias, E., & Bloomer, M. 2023).

Forty-nine-point three percent (n = 212) of the 430 adult patients who

passed away were foreign-born, 56.9% (n = 245) classified as religious, and

14.9% (n = 64) spoke a language other than English as their first language. In

4.9% (n = 21) of the family meetings, there were professional interpreters

present. In 82.1% (n = 353) of the patient records, information regarding the

degree of treatment limitation decisions was recorded. For 49.3% (n = 174) of the

patients, nurses were noted as being present during conversations about therapy

limitations. In situations when nurses were present, they provided comfort to

family members and guaranteed that their final desires would be honored. There

was proof that nurses were organizing medical procedures and making an effort

to talk to and help family members with their problems.

This is the first Australian study that is aware of that examines

documented evidence of how patients from varied cultural backgrounds are

informed about treatment restrictions. The fact that some patients pass away

before their family can discuss treatment restrictions despite the fact that many

have documented constraints may have an impact on the timing and standard of

end-of-life care. Interpreters should be utilized where there are language issues

to ensure that families and clinicians communicate effectively. More opportunities

for nurses to participate in discussions about treatment limitations are needed.

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Research Framework
1 2 3 4
RESEARCH DATA EXPECTED INTERVENTION
OBJECTIVE GATHERING RESULTS/OU PLAN/PROGR
PROCESS TPUT AM
 Evaluate the
accuracy and  Respondents  Recurring  Provide
completeness use a checklist mistakes or additional
of the inpatient to assess discrepancies training
medical documentation in specific sessions or
record. of medical departments, workshops for
 Identify record/chart. types of staff on proper
recurring records, or documentation
errors or areas among certain practices.
of staff members.  Regularly
improvement conduct follow-
in the up audits to
documentation track
process. improvements
and address
persisting
issues.

The goal of this study is to create a systematic structure for the medical

records audit team to support the provision of healthcare services in our hospital

and assess the quality, accuracy, completeness, and compliance of medical

documentation. Data from the respondents of the Nursing Service Staff were

collected through questionnaire analysis and observation for the study, which

was primarily qualitative. Out of the many Nursing Service staff of J.R. Borja

General Hospital, twenty (20) nurse supervisors responded. The study found
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that there are mistakes or discrepancies and inconsistencies in the inpatient

medical records in J.R. Borja General Hospital for many reasons, which further

demonstrates the need for a new structure for managing medical records in all

their forms and across all concerned departments of this hospital. For efficient

records administration and easy access, the study develops and offers a revised

structure for integrating medical records management into the workflow of

providing healthcare services. It is believed that such a revision of the structure

will assist J.R. Borja General Hospital in improving its administration of medical

records to enhance the delivery of healthcare services.

RESEARCH PROBLEMS

The study aimed to obtain a comprehensive understanding of the medical

records auditing procedure, difficulties encountered, opinions, and suggestions

for enhancement from relevant parties.

Specifically, the study sought to answer the following problems:

1. What insights the respondents can share about the status and process of

doing the Patient's medical record audit in the hospital?

2. In the conduct of an inpatient medical record audit, what are the major

pressing issues encountered by the respondents?

3. What kind of intervention strategy and set of rules should be developed to

successfully conduct a volume audit study on patient medical charts or

records?
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SIGNIFICANCE OF THE STUDY

A study on the inpatient medical records audit has advantages for all

hospital stakeholders. The Nursing Service Department, Doctors, Billing Section,

and the Medical Records Office benefit from these improved documentation

practices. Complete and accurate medical records can lower the risk of medical

errors, improve continuity of care, and help decision-makers make more

educated choices. It impacts J.R. Borja General Hospital itself and patient care.

The Nursing Service Department benefit to have the medical records

audited and serves as a technique to examine the quality and accuracy of

nursing paperwork and ensuring that records are thorough and precise is crucial

in maintaining high standards of care delivery.

This study helps the billing section to guarantee correct billing and

supports the healthcare organization's financial viability. The financial stability of

the organization is positively impacted by appropriate reimbursement that arises

from proper billing procedures based on comprehensive documentation.

This study helps the Medical Records Office to make sure that

documentation standards and regulations are followed. This covers following

privacy regulations and guidelines on how to make record-keeping procedures

better. This makes it possible for the Medical Records Office to improve

documentation procedures, put corrective measures into place, and keep

providing better services.

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This study also holds substantial significance within hospitals for it

demonstrates a commitment to excellence in healthcare delivery and continuous

improvement in record-keeping standards.

METHODOLOGY

Research Design and Instrument

A grounded theory was used in this study to explain the factors influencing

documentation practices of the inpatient medical records in J.R. Borja General

Hospital. The researcher conducted semi-structured interviews with the JRBGH

Nursing Service staff who were mainly the respondents of this study, and carried

out the audit of the inpatient medical record/chart before the patients were about

to be discharged from admission.

Respondents and Setting

The main respondents of this study are the twenty (20) Nurse Supervisors

of each Nursing Station of J.R. Borja General Hospital. They have been in J.R.

Borja General Hospital and have been assigned to different stations. They

assess the completeness of the inpatient medical records before it is endorsed to

the billing section for the generation statement of account.

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The study took place at the J.R. Borja General Hospital, Carmen,

Cagayan de Oro City, Misamis Oriental. A newly upgraded Level 2 LGU

healthcare institution with a 175-bed capacity. The geographical area was used

because this study aims to provide an accurate representation of hospitals in

Northern Mindanao.
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Figure 1. The vicinity map of J.R. BORJA GENERAL HOSPITAL

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Data Gathering Procedure

During the interview, an audit checklist was available for the respondents,

and it was also attached to the charts of the inpatients who had been chosen at

random and were set to leave the hospital. This checklist is used for the

evaluation of the completeness of the medical record and is also used in the data

collection.

The researcher obtained a study permit approval from the acting chief of

the hospital for the interview questions. The interviews were conducted from the

month of August to September of 2023 and the respondents were interviewed in

their assigned stations. The respondents were chosen based on their

participation in the medical records audit.

The data collected were primary and the source was the “May go home”

or about to be discharged patients’ chart available during the day of the interview.
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RESULTS AND DISCUSSION

Research Question Responses

Problem #1:  In the current process of the inpatient medical

What insights the records audit, a checklist is attached to the

respondents can share patient's chart that serves as a guideline in the

about the status and checking. The objective of the checklist is to

process of doing the determine the completeness. All (100%) of the

Patient's medical record respondents followed the checklist in auditing

audit in the hospital the patient's medical record/chart to check if

the documents were correct and accurate.

The audit starts from the time the patient is

admitted until the end of the stay in the

hospital. The nurse supervisors or the team

leader are the first auditors and are primarily

responsible for verifying the records.

An audit can be carried out methodically by following the guidelines on

a checklist that is affixed to the patient's chart. Its goal is to guarantee that the

patient's medical record is complete. The emphasis on completeness points

toward a focus on confirming the existence of all records and information

needed for accurate records. It is observed that during the auditing procedure,

every respondent (100%) followed this checklist. This highlights the methodical
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approach that the team leaders or nursing supervisors have adopted,

guaranteeing uniformity in the audit process and demonstrating a dedication to

the defined methodology. From the time of the patient's admission until their

release from the hospital, the audit procedure is ongoing. This all-inclusive

method allows for a comprehensive evaluation of the medical record during the

hospitalization period, covering the whole course of the patient's stay. These

people are the main auditors in charge of first confirming the documents. Their

function demonstrates how important it is that they make sure the medical

records are accurate and comprehensive.

Problem #2:  19 out of 20 (95%) of the respondents said that

In the conduct of a patient's the usual mistakes or discrepancies

medical record audit, what discovered were missing documentation,

are the major pressing incorrect data entry, outdated information,

issues encountered by the inconsistent coding, and unresolved

respondents? discrepancies.

o Missing Documentation: Chart audits

frequently reveal instances where

crucial patient information, such as

vital signs, medication

administration, or progress notes, is

not properly documented or entirely

missing from the medical records.

o Incorrect Data Entry: Errors in data

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entry, such as typos or transposed

digits, can lead to inaccuracies in

patient details, lab values,

medication dosages, and other

critical information within the medical

charts.

o Outdated Information: Audits may

uncover instances where outdated

information, such as patient history,

allergies, or treatment plans, is still

present in the medical records,

potentially impacting decision-

making for ongoing care.

o Inconsistent Coding: When

reviewing billing and coding

information, discrepancies can arise

between the diagnoses documented

in the patient's chart and the codes

used for billing purposes, leading to

reimbursement issues and

potentially affecting the accuracy of

patient records.

o Unresolved Discrepancies: Audits

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often bring to light unresolved

discrepancies or inconsistencies

between different sections of the

medical records, such as

mismatched medication lists,

contradictory treatment plans, or

conflicting diagnosis information.

 To address the issues related to incomplete or

missing documentation, the auditor reached

out to the personnel responsible for the

incomplete documentation.

Ninety-five percent (95%) of the participants, or the respondents,

emphasized certain problems they had while doing the audit. These problems

consist of incomplete paperwork, inaccurate data entry, out-of-date material,

inconsistent coding, and unsolved disparities. This collective input highlights

issues that keep coming up in the medical records and directs attention to areas

that need to be improved right away.

Problem #3:  19 out of 20 (95%) of the respondents say that

What kind of intervention if inadequate documentation is a recurring

strategy and set of rules issue, they considered providing additional

should be developed to training or orientation to refresh the policies on

successfully conduct a the documentation process regarding audits.

volume audit study on They also considered that an enhanced

patient medical charts or checklist should be crafted to improve the

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records? quality of the medical records audit. 18 out of

20 respondents suggest that it should

concentrate on the most affected sheets that

need completion. A program of work or an

activity design is included in the plan for the

preparation of the said activity.

Ninety-five percent (95%) of the respondents indicated that they would

think about offering more orientation or training sessions. The purpose of this

course is to update the policies and procedures about audit-related

documentation processes. This acknowledgment shows that the respondents

understand the importance of continual education or procedure reinforcement to

reduce recurrent problems. To raise the standard of the medical records audit,

the respondents also suggested developing an improved checklist. Focusing

efforts on this checklist is crucial, according to 18 out of 20 respondents. This

suggestion emphasizes how important it is to have a more thorough,

streamlined, and detailed checklist that addresses the particular issues found

during the audits.

According to the results of the interview conducted by the

researcher, 90% or 18 of the 20 respondents while addressing any

documentation-related issues adhere to established protocols and guidelines.

FINDINGS
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Problem #1

Based on the results of the interview, twenty (20) or 100% of the

respondents relied on the checklist as guidelines for them to know the accuracy

and completeness of the patient’s chart. They said that the main objective of this

study is to ensure the quality of patient care by doing an audit to identify and

rectify issues that could compromise patient safety. Results of the interview

revealed that among the staff involved in the inpatient medical records audit

process, the nurses are primarily responsible for the completion of the missing

documents and discrepancies in the record.

Problem #2

Through the audit of inpatient medical records across multiple

departments, it was observed that missing documentation, incorrect data entry,

outdated information, inconsistent coding, and unresolved discrepancies are

frequently incomplete. In light of the results, respondents make a list or

document the instances where information is lacking or incomplete. This will help

in organizing and addressing each issue systematically, calling the attention of

the concerned staff to completion of the missing documents. Reaching out to

them is their priority before the patient is officially discharged. The

documentation was evaluated and appeared to be aligned and in compliance

with the standards of the Department of Health (Hospital Information and

PhilHealth.
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Problem #3

As a function of the interview results, the respondents' primary goal is to

identify areas for improvement in documentation processes and workflow and to

have accurate and comprehensive records to reduce the chances of errors in

diagnosis, treatment, or medication, thereby improving patient safety. Based on

the outcome, of a volume audit study of medical records, respondents primarily

focused on Missing Documentation, Incorrect Data Entry, Outdated Information,

Inconsistent Coding, and Unresolved Discrepancies. A thorough evaluation of

these areas guarantees a thorough comprehension of the completeness and

quality of the medical records kept in a healthcare facility. The respondents

implemented targeted training programs focusing on the improvement of the

documentation process. This program contributes to better patient outcomes,

enhanced overall quality of care, and more effective hospital operations.

CONCLUSION

Based on the study’s findings, the qualitative analysis conducted as part of

this inpatient medical records audit has revealed critical insights into the

documentation practices within J.R. Borja General Hospital. Throughout this

audit, several key themes emerged. However, a few areas were identified for

improvement, particularly in ensuring consistent recording of Missing

Documentation, Incorrect Data Entry, Outdated Information, Inconsistent Coding,

and Unresolved Discrepancies across all departments. Even though the staff
 23

members showed a strong commitment to providing quality patient care, the

researcher found issues with consistency, completeness, and regulatory

compliance in the paperwork.

The impact of incomplete or inaccurate documentation on patient care and

operational efficiency cannot be understated. It complicates the continuity of

care across departments, poses potential risks to patient safety, and hampers

effective decision-making. Our recommendations for improvement consist of a

revision of checklists and creation of deficiency slips, and targeted

training/orientation.

RECOMMENDATIONS

This study uncovered several key themes and problems, it also pinpointed

specific areas requiring immediate attention to ensure uniformity in recording

practices across all departments. The issues of Missing Documentation, Incorrect

Data Entry, Outdated Information, Inconsistent Coding, and Unresolved

Discrepancies underscore the need for cohesive improvement measures. These

newfound insights into documentation practices are the result of a thorough

qualitative analysis conducted during the inpatient medical records audit at J.R.

Borja General Hospital.

Even with the staff's admirable commitment to delivering high-quality

patient care, there were clear discrepancies, omissions, and regulatory violations

in the documentation. It is critical to acknowledge the significant effects that

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erroneous or incomplete records have on patient care and operational

effectiveness. These disparities jeopardize patient safety, complicate the

continuity of care, and make it more difficult to make well-informed decisions.

RECOMMENDED INTERVENTION PLANS/PROGRAM

RESOURCES DEPARTMENT
PROGRAMS OBJECTIVES
NEEDED IN-CHARGE

Revision of
To enhance the Venue, Snacks, Medical Records
Checklist and
audit process and Speakers
Creation of Office
(Nursing Service
Deficiency Slip
and Medical
Records Office
Representative)
Budget: 5,000
To discuss the Php/session x 6 Nursing Service &
Orientation sessions = Medical Records
enhancement of
the audit process P30,000.00 Office

One way to provide actionable recommendations to address deficiencies

and improve the quality of medical records is for J.R. Borja General Hospital will

conduct training programs, process improvements, or policy changes. Its

intervention is to create an action plan that outlines the steps to put the

recommendations into practice, assigns roles, and sets deadlines for

improvement. One program to craft is the revision of the checklist and creation of

the Deficiency Slip. This enhancement will be integrated into the policy of the

medical records audit for the implementation of the plan. A program of work or
 25

an activity design will be crafted stating the need for an orientation for the said

activity. The source of funds is taken from the annual budget under special

programs/projects in the amount of P30,000.00 for venue preparation, snacks,

and speakers. Participants will be composed of the Nursing Service Staff,

Doctors, Billing Clerks, Medical Records Office Staff, and others concerned with

the medical records audit process.

Additionally, conducting recurring internal audits and quality checks could

guarantee ongoing compliance and reinforce adherence to documentation

requirements.
 26

REFERENCES

Azzolini, E., Furia, G., Cambieri, A., Ricciardi, W., Volpe, M., Poscia, A., (2019).
https://www.researchgate.net/publication/336988206_Quality_improveme
nt_of_medical_records_through_internal_auditing_a_comparative_analysi
s

Brooks, L., Manias, E., & Bloomer, M. (2023). A retrospective descriptive study of
medical record documentation of how treatment limitations are
communicated with family members of patients from culturally diverse
backgrounds. Australian Critical Care.
https://doi.org/10.1016/j.aucc.2023.04.007

Casuriaga, A., Giachetto, G., Gutiérrez, S., Martínez, V., Garcı́A, A. M., Martínez,
F., De Olivera, N., & Boulay, M. (2018). Auditoría de historias clínicas: una
herramienta de evaluación de la calidad asistencial. Hospital Pediátrico -
Centro Hospitalario Pereira Rossell. Archivos De Pediatría Del Uruguay,
89(4), 242–250. https://doi.org/10.31134/ap.89.4.3

Delosa, S., Delosa, R. Jr., (2020) Implementation of Records Management

System in Cotabato Regional Medical Center Health Information
Management Department.,
https://www.researchpublish.com/papers/implementation-of-records-
management-system-in-cotabato-regional-medical-center-health-
information-management-department

Gasoma, E. (2022). Retrospective audit in documentation practice in surgical

inpatients records, a two cycles audit. Irish Journal of Medical Science
(1971 -), 192(5), 2345–2349. https://doi.org/10.1007/s11845-022-03224-2

Nurlu, D., & Raoof, A. (2023). Inpatient ward review documentation audit. British
Journal of Psychiatry Open, 9(S1), S172–S173.
https://doi.org/10.1192/bjo.2023.454
 27

APPENDICES

Appendix A. Letter Request to conduct the study.

 28

Appendix B. Interview Guide Questionnaire

 29

Appendix C. Present Checklist

 30

Appendix D. The researcher conducted interviews with the Nurse Supervisor

respondents in J.R. Borja General Hospital

 31

Appendix E. Certificate of Editing

PROOFREADING CERTIFICATE | January 7, 2024

 32

To whom it may concern,

This is to confirm that the document described below has been submitted for
editing and proofreading.

Document Title: EMERGING ISSUES OF THE INPATIENTS’ MEDICAL

RECORDS AUDIT AT J.R. BORJA GENERAL HOSPITAL

Author(s): Michael C. Iyoy

This document certifies that the above manuscript was proofread and edited for
proper English language, grammar, punctuation, spelling, and overall style prescribed by
Academic Writing. The researcher/author(s) may accept or reject each change
individually. We bear no responsibility for revisions made to the manuscript after our edit
on the date listed. The undersigned proofreader guarantees high language accuracy of the
manuscript without altering the intent and content of the study written by the author/s;
hence, the researchers were sought for clarification and verification.

This certification is issued for whatever legal purpose it may serve. Given this on
th
the 7 of January, 2024 at Cagayan de Oro City.

Respectfully,

Gabrielle E Sunogan-Aleligay, LPT, MATESL

PRC License No.: 1614198

+63-997-1263450
Cagayan de Oro City, 9000
sunogan.gabrielle@gmail.com

CURRICULUM VITAE
 33

Name : Michael Casinillo Iyoy

Address: Block 27 Lot 5, Acacia Street, Forest View Homes, Zone 13,

Carmen, Cagayan de Oro City, Misamis Oriental

Date of Birth: June 3, 1974

Place of Birth: Cebu City, Philippines

Religion: Christian

Educational Background:

Elementary: South City Central School

Secondary: Southern de Oro Philippines College

Tertiary: Xavier University Ateneo de Cagayan

Vocational: Philippine Women’s College

Graduate: Cagayan de Oro College - Phinma Education Network

Eligibility: Career Service Professional March 2019

Work Experience: Administrative Officer III – present JRBGH

Admin Aide IV JRBGH

Nursing Attendant JRBGH

Admin Aide III JRBGH

Claims Processor XU-CHCC

 34

Seminar Workshop/ Training Attended:

 Dissemination/Orientation of the Hospital Information Management Manual,

April 2023

 Motivating and Understanding People and Effective Leadership in the

Workplace, November 2022

 Customer Service Delight & the 7 Deadly Sins of Customer Service,

November 2022

 Medical Certification of Cause of Death Assessment in Health Facilities,

October 2022

 Health Information Management Training Course, April 2022

 Data Privacy Act in Health Information Management - Experiences &

Challenges, April 2022

 Death Certificate Assessment - The Role of HIMU Staff, March 2022

 Virtual Conference: Best Practices & Strategies in Patient Confidentiality and

Privacy, November 2021

 One Hospital Command Center Orientation among Bed Tracker Managers,

July 2021

 Training Workshop in the Filling Up & Registration of the Certificates of Live

Births, Deaths, Marriages and its Integral Parts, July 2021

 Health Information Management Training Course, March 2021