Format F/001/MRD

Audit - Medical Record Completion

MRN: IP No.: OPEN FILE CLOSED FILE

DOA: DOD: / / / / / / / / Remarks
Diagnosis:
Y N NA Y N NA Y N NA Y N NA
Initial Assessment is done by Doctors
immediately/within stipulated time.
Plan of care within 24 hours
Allergies on admission & treatment noted
(Form 7 to 1593, & 99a)

Current Medications noted

ASSESSMENTS

Pain Assessment by Medical & Nursing

Educational, Functional, Learning
Assessment is done by Medical & Nursing
Patient Family Education is done
Daily Pain Scoring
Initial Assessment done by Nursing within
2 hours
Nutritional Assessment is done
Authorized abbreviations & symbols used
Daily Reassessments are done
All Consents are Complete
(Form 20-31b)
CONSENTS

No abbreviations (Diagnosis, Procedure)

Risks, benefits, complications, and alter-
natives of Anesthesia & Surgery mentioned
Patient’s / Relative’s / NOK signature
Clinician & Witness’s signature
Preoperative assessment is documented
before anesthesia or surgical treatment.
(F 33,40,48,&55a)

Date, Time & Sign of Surgeon & Nurse

SURGERY

Preoperative Time Out is done

Intra & Post Op monitoring (Anesthesia)
Blood Loss & Specimen details on OT Notes
Authorized abbreviations & symbols used
Pre & Post Operative Diagnosis
Doctor notes date, time, sign, Name & ID
PROGRESS

Nurses notes date, time, sign, Name & ID

NOTES

Authorized abbreviations & symbols used

Daily Pain Assessment
Discharge Instructions & Care given
Medication names in CAPITAL/Legible
Allergies noted & signed
CHART (F 91)
MEDICATION

Authorized abbreviations & symbols used

Dose, Strength, Frequency, Route, Date &
Time
Administration verified by Second Nurse
Monitoring done by Clinical Pharmacist
F 92 Clinical Chart Complete
Blood Transfusion Consent
TRANSFUSION

Blood Transfusion start & end time noted

BLOOD

Vitals monitored frequently in process

Adverse reactions noted (if any)
Doctor’s Signature

Revision 2
 Format F/001/MRD

Audit - Medical Record Completion

OPEN FILE CLOSED FILE

/ / / / / / / / Remarks
Y N NA Y N NA Y N NA Y N NA
In-house Transfer form
All Investigation Reports (Original / Copy)
Planned Discharge
No ABBREVIATIONS in DIAGNOSIS &
DISCHARGE SUMMARY

PROCEDURE
ICD Coding (Diagnosis & Procedure)
Investigation findings
Details of Procedures performed
Medications given
Instructions regarding how & when to
obtain urgent care
Follow up & Medication Advice
Treating Consultant’s signature
General Consent is signed by relative
(Admission Form)
Clinical Pathways - Complete date, time,
sign, Name & ID
Physiotherapy Assessment - Complete
date, time, countersigned, Name & ID
(If Applicable)

ICU Daily Goals Checklist

OTHERS

Restraint Assessment & Consent

Consultation Referral Sheet
Safety First
Diabetic Chart
Acknowledgement form
MLC intimation copy & stamp
Death Intimation Certificate
Form 4 Cause of Death – ICD Coding
Death Summary
Record Review by:
Sign & ID

Audited by: Verified by: Authorized By:

(Name) (Consultant Incharge) (Medical Administration)

Revision 2