MONTH:- ( Aug 2018) MEDICAL RECORD AUDIT CHECKLIST

S.No. DESCRIPTION OF RECORDS Sample Compliances

1 Initial Patient Registration

1. Patient details with address.
720 719
2. Referred Doctor Name. 482 480
3. Consulting Doctor Name. 356 352
4. Requested category alloted. 720 720
5. Name & Sign by Admitting Clerk. 720 720
6. Name & Sign by Patient/Relative. 717 715
7. Name & sign of witness ( In case patient unconsious. 203 201
8. Name & sign by Patient/Relative/witness on consent and
case sheet.
720 719
Total
2 In-Patient History and Physical record
1. Patient details 720 715
2.Chief Complaints 720 715
3. History of past illness -Medical & surery(if any) 704 693
4. Current Medication 675 649
5. Occupation 594 327
6. Allergies 656 626
7. Physical Examination/Vital Signs 718 708
8.Pain Score 674 512
9.Diagnosis 703 642
10.Investigation Advised 662 465
11. Diet Advised 637 459
12. Patient /Relative Name and Sign 689 627
13. SNDT of RMO 719 705
Total
3 Nursing Assessment Form
1.Patient Details 720 720
2.Physical Assessment 720 720
3.Fall Risk Assessment 720 591
4.Pain Score 720 704
5.Nursing Care Plan 720 720
6. SNDT of Staff nurse 720 720
Total

4 Nutritional Assessment Form

1. Patients Details 138 138
2. Food Allergies if any 138 138

3. Screening 138 138

4. SNDT of Dietician 138 138

 Total
5 Continuation Sheet

1. Patient Details 720 720

2. Morning Doctors Notes with SNDT 718 692
3. Evening Doctors Notes with SNDT 712 684
4. Night Doctors Notes with SNDT (specially In case of
emergency admission)
192 192
Total
6 Nurses' Notes & Handover
1. Morning Notes/ SNDT 719 706
2. Evening Notes/SNDT 694 683
3. Night Notes/ SNDT 695 683
Total
7 Medication Chart
1. Patients Details 710 710
2. Medication in capitals with appropriate dose,feq,route 709 634
3.Sign of RMO against medicines 709 17
4. Medication administred according to frequency 710 710
Total
8 Physiotherapy Reassessment
1. Physiotherapy Notes 40 11
2. SNDT of Physiotherapist 40 11
Total
9 (TPR/BP)/Intake output chart
1. Patient Details 720 720
2. Temperature 720 720
3. Pulse/RR 720 719
4. SPO2 57 56
5. BP 689 678
Total
10 Transfer sheet
1. Patient details 247 247
2. Date and time of transfer 247 243
3 Transfer from and transfer to is mentioned 247 242
4. Part A ( To be filled by Nursing Staff )
5. Vitals Signs 247 244
6. Reason for Transfer 247 242
7. Part B ( To be filled by Doctor)
9. CVS 247 246
10. Respiratory 247 243
11. Abdomen 247 242
12.Transferring nurse SNDT 247 247
13.Receiving Nurse SNDT 247 244
14.RMO SNDT 247 236
 Total
11 Informed Consent for Blood Transfusion
1. Patient Details 181 181
2. Patients ABO RH Group 181 181
3. SNDT of Patient Name/ Attendent 181 179
4. SNDT OF Consultant/RMO 181 180
Total
12 LAMA/DOR Consent
1. Patients Details. 190 190
2. Patients Sign, Date & time. 154 67
3. Details of patients Relatives name and sign. 189 187
4. Name and sign of witness. 156 111
5. SNDT of Doctor. 190 177
Total
13 Inform consent for High Risk
1. Patient details 318 317
2. Medical condition/Diagnosis 318 301
3. Operative Procedure/Operation 318 300
4.Patient SNDT 315 313
5.Witness SNDT, 318 273
6. Duty doctor's signature 318 273
7. SNDT of Surgeon 318 312
Total
14 Blood / Component Transfusion Order
1. Patint details 182 182
2. Blood Bag No. 182 181
3. Blood/Blood Components 182 181
4. Date of Expiry 182 182
5. Blood Transfusion Reaction 182 181
6. Start & Finish Time 182 180
7. Sign of Staff Nurse 182 181
8.SNDT of RMO/Consultant 182 180
Total
15 HIV Consent
1. Patient details 130 130
2. SNDT of Patient or witness 129 125
3.SNDT of Doctor 127 106
Total
16 Informed Consent for Surgical Operation
1. Patient details 308 308
2.Surgery mentioned 308 308
3.SNDT of Doctor 308 305
4.SNDT of patient or Witness, relationship 308 307
 Total
17 Consent for Anaesthesia
1.Patient details 308 308
2. Anaesthesia Plan 308 296
3.SNDT of Patient or Guardian, Witness 308 308
4. SNDT of Anesthetist 308 307
Total
18 Anaesthetic form
1. Pre anaestheisa
1.Patient Details 308 308
2. Anaesthesia Plan 308 292
3.Appropriate assessment as per defined parameters 308 302
4. SNDTof Anaesthetist 308 308
2 .Immediate Pre OP Re-evaluation done-type of
anesthesia mentioned. 308 303
3.Intra OP
1. vitals, Other monitoring done 308 301
2. Anaesthesia given mentioned 308 304
3. Appropriate monitoring done 308 302
4.SNDT OF ANESTHETIST 308 306
Total
4. Post OP
2. Post OP Orders 307 307
3. SNDT of Anaesthetist 307 307
19 Surgical safety checklist
1. Patient details 308 308
3.Site/side marking done 308 306
4. All parameters checked 308 305
5. SNDT of Anaesthetist, surgeon & nurse 308 302
Total
20 Operation Records
1. Patient details 318 317
2.Consultant Name 318 314
3. Date/Time of surgery 317 293
4.Surgery 318 292
5. Pre & Post OP diagnosis 318 218
6.Pocedure/Operation Notes 318 308
7.Post OP care plan 318 318
8.Post OP treatment orders 318 318
9.SNDT of Surgeon 318 316
Total
21 Death Summary
1.Patient Details 1 1
2. Diagnosis 1 1
3.cause of death 1 1
 4. History 1 1
5. Hospital course 1 1
6.Consultant Name,Sign 1 0
7. RMO Name,Sign 1 0
Total
22 Discharge Summary
1. Patients Details 719 719
2. Diagnosis 719 719
3. Procedures (If Any) 2 2
4. Surgery ( If Any) 325 325
5. Past History 719 719
6.Examination/Findings 719 719
7. Course in hospital (operation notes) 718 718
8. Investigation(Lab, Radiology, others) 719 718
9. Condition at discharge 720 719
10. Advice on discharge 721 719
11.Follow up Advice 722 719
12.when to obtain urgent care is mentioned 723 718
13.Proper Name & sign of Doctor 713 648

AUDITOR NAME AND SIGN: Archana Chouhan

KLIST
pliances Non - Compliances percentage

19 1 99.86%
80 2 99.59%
52 4 98.88%
20 0 100.00%
20 0 100.00%
15 2 99.72%
01 2 99.01%
19 1 99.86%

15 5 99.31%
15 5 99.31%
93 11 98.44%
49 26 96.15%
27 267 55.05%
26 30 95.43%
08 10 98.61%
12 162 75.96%
42 61 91.32%
65 197 70.24%
59 178 72.06%
27 62 91.00%
05 14 98.05%

20 0 100.00%
20 0 100.00%
91 129 82.08%
04 16 97.78%
20 0 100.00%
20 0 100.00%

38 0 100.00%
38 0 100.00%

38 0 100.00%

38 0 100.00%
20 0 100.00%
92 26 96.38%

84 28 96.07%
92 0 100.00%

06 13 98.19%
83 11 98.41%
83 12 98.27%

10 0 100.00%
34 75 89.42%
17 692 2.40%
10 0 100.00%

11 29 27.50%
11 29 27.50%

20 0 100.00%
20 0 100.00%
19 1 99.86%
56 1 98.25%
78 11 98.40%

47 0 100.00%
43 4 98.38%
42 5 97.98%

44 3 98.79%
42 5 97.98%

46 1 99.60%
43 4 98.38%
42 5 97.98%
47 0 100.00%
44 3 98.79%
36 11 95.55%
81 0 100.00%
81 0 100.00%
79 2 98.90%
80 1 99.45%

90 0 100.00%
67 87 43.51%
87 2 98.94%
11 45 71.15%
77 13 93.16%

17 1 99.69%
01 17 94.65%
00 18 94.34%
13 2 99.37%
73 45 85.85%
73 45 85.85%
12 6 98.11%

82 0 100.00%
81 1 99.45%
81 1 99.45%
82 0 100.00%
81 1 99.45%
80 2 98.90%
81 1 99.45%
80 2 98.90%

30 0 100.00%
25 4 96.90%
06 21 83.46%

08 0 100.00%
08 0 100.00%
05 3 99.03%
07 1 99.68%
08 0 100.00%
96 12 96.10%
08 0 100.00%
07 1 99.68%

08 0 100.00%
92 16 94.81%
02 6 98.05%
08 0 100.00%
03 5 98.38%

01 7 97.73%
04 4 98.70%
02 6 98.05%
06 2 99.35%

07 0 100.00%
07 0 100.00%

08 0 100.00%
06 2 99.35%
05 3 99.03%
02 6 98.05%

17 1 99.69%
14 4 98.74%
93 24 92.43%
92 26 91.82%
18 100 68.55%
08 10 96.86%
18 0 100.00%
18 0 100.00%
16

1 0 100.00%
1 0 100.00%
1 0 100.00%
1 0 100.00%
1 0 100.00%
0 1 0.00%
0 1 0.00%

19 0 100.00%
19 0 100.00%
2 0 100.00%
25 0 100.00%
19 0 100.00%
19 0 100.00%
18 0 100.00%
18 1 99.86%
19 1 99.86%
19 2 99.72%
19 3 99.58%
18 5 99.31%
48 65 90.88%
 JAN FEB MAR APR MAY
Initial Patient Registration
1. Patient details with address. 120 120 120 120 120
2. Referred Doctor Name. 73 72 80 83 81
3. Consulting Doctor Name. 63 71 50 52 63
4. Requested category alloted. 120 120 120 120 120
5. Name & Sign by Admitting Clerk. 120 120 120 120 120
6. Name & Sign by Patient/Relative. 118 117 120 120 120
7. Name & sign of witness ( In case patient 37 38 34 31 27
unconsious

8. Name & sign by Patient/Relative/witness 120 119 120 120 120

on consent and case sheet.

In-Patient History and Physical record

1. Patient details 120 120 120 120 119
2.Chief Complaints 120 120 120 120 119
3. History of past illness -Medical & surery(if any) 116 117 115 118 113
4. Current Medication 111 109 106 111 107
5. Occupation 60 56 51 50 51
6. Allergies 99 112 100 104 100
7. Physical Examination/Vital Signs 119 119 118 117 119
8.Pain Score 84 75 83 91 83
9.Diagnosis 103 104 104 111 110
10.Investigation Advised 85 78 60 83 78
11. Diet Advised 77 83 62 89 67
12. Patient /Relative Name and Sign 89 101 108 106 110
13. SNDT of RMO 119 119 118 117 118
Total
Nursing Assessment Form
1.Patient Details 120 120 120 120 120
2.Physical Assessment
120 120 120 120 120
3.Fall Risk Assessment 86 94 96 100 102
4.Pain Score 119 116 113 116 120
5.Nursing Care Plan 120 120 120 120 120
6. SNDT of Staff nurse 120 120 120 120 120
Total

Nutritional Assessment Form

1. Patients Details 24 19 20 25 28
2. Food Allergies if any 24 19 20 25 28
3. Screening 24 19 20 25 28
4. SNDT of Dietician 24 19 20 25 28
Total
Continuation Sheet
1. Patient Details 120 120 120 120 120
2. Morning Doctors Notes with SNDT 117 119 114 115 116
3. Evening Doctors Notes with SNDT 117 116 112 112 110
4. Night Doctors Notes with SNDT (specially In
case of emergency admission)
34 37 27 32 35
Total
Nurses' Notes & Handover
1. Morning Notes/ SNDT 115 118 116 120 119
2. Evening Notes/SNDT 119 117 115 117 96
3. Night Notes/ SNDT 117 116 117 117 98
Total
Medication Chart
1. Patients Details 118 113 120 119 120
2. Medication in capitals with appropriate
dose,feq,route
52 109 115 119 119
3.Sign of RMO against medicines 2 0 3 1 7
4. Medication administred according to frequency 118 113 120 119 120
Total
Physiotherapy Reassessment
1. Physiotherapy Notes 6 0 3 0 1
2. SNDT of Physiotherapist 6 0 3 0 1
Total
(TPR/BP)/Intake output chart
1. Patient Details 120 120 120 120 120
2. Temperature 120 120 120 120 120
3. Pulse/RR 120 120 120 120 120
4. SPO2 0 0 28 7 6
5. BP 109 110 114 112 114
Total
Transfer sheet
1. Patient details 51 40 43 32 46
2. Date and time of transfer 51 39 43 32 44
3 Transfer from and transfer to is mentioned 51 39 42 32 44
4. Part A ( To be filled by Nursing Staff )
5. Vitals Signs 51 39 43 32 45
6. Reason for Transfer 51 39 42 32 45
7. Part B ( To be filled by Doctor)
9. CVS 51 40 43 32 45
10. Respiratory 51 40 43 32 42
11. Abdomen 51 40 43 32 42
12.Transferring nurse SNDT 51 40 43 32 46
13.Receiving Nurse SNDT 51 40 42 32 45
14.RMO SNDT 51 38 43 32 37
Total
Informed Consent for Blood Transfusion
1. Patient Details 24 33 34 27 32
2. Patients ABO RH Group 24 33 34 27 32
3. SNDT of Patient Name/ Attendent 22 33 34 27 32
4. SNDT OF Consultant/RMO 24 33 34 27 32
Total
LAMA/DOR Consent
1. Patients Details. 34 26 28 34 37
2. Patients Sign, Date & time. 11 9 9 15 10
3. Details of patients Relatives name and sign. 33 26 28 34 36
4. Name and sign of witness. 24 20 11 19 22
5. SNDT of Doctor. 32 24 26 31 37
Total
Inform consent for High Risk
1. Patient details 49 50 55 59 50
2. Medical condition/Diagnosis 46 44 52 57 49
3. Operative Procedure/Operation 46 44 52 57 48
4.Patient SNDT 47 49 55 60 49
5.Witness SNDT, 49 5 55 60 50
6. Duty doctor's signature 42 41 48 53 39
7. SNDT of Surgeon 49 49 53 60 48
Total
Blood / Component Transfusion Order
1. Patint details 24 34 34 27 32
2. Blood Bag No. 24 34 33 27 32
3. Blood/Blood Components 24 34 33 27 32
4. Date of Expiry 24 34 34 27 32
5. Blood Transfusion Reaction 24 34 34 27 32
6. Start & Finish Time 24 34 34 27 31
7. Sign of Staff Nurse 24 34 34 27 32
8.SNDT of RMO/Consultant 23 34 34 27 32
Total
HIV Consent
1. Patient details 27 16 31 24 16
2. SNDT of Patient or witness 24 16 30 23 16
3.SNDT of Doctor 24 9 28 16 15
Total
Informed Consent for Surgical Operation
1. Patient details 49 50 45 60 50
2.Surgery mentioned 49 50 45 60 50
3.SNDT of Doctor 49 49 44 60 50
4.SNDT of patient or Witness, relationship 49 50 45 60 49
Total
Consent for Anaesthesia
1.Patient details 49 50 45 60 50
2. Anaesthesia Plan 44 47 43 58 50
3.SNDT of Patient or Guardian, Witness 49 50 45 60 50
4. SNDT of Anesthetist 49 49 45 60 50
Total
Anaesthetic form
1. Pre anaestheisa 49 50 45 60 50
1.Patient Details 49 50 45 60 50
2. Anaesthesia Plan 47 46 41 58 48
3.Appropriate assessment as per defined
parameters
49 47 42 60 50
4. SNDTof Anaesthetist 49 50 45 60 50
2 .Immediate Pre OP Re-evaluation done-type of
anesthesia mentioned.
49 50 42 58 50
3.Intra OP
1. vitals, Other monitoring done 48 47 43 59 50
2. Anaesthesia given mentioned 48 49 44 59 50
3. Appropriate monitoring done 48 48 43 59 50
4.SNDT OF ANESTHETIST 49 49 45 59 50
Total
4. Post OP
2. Post OP Orders 49 50 45 60 49
3. SNDT of Anaesthetist 49 50 45 60 49
Surgical safety checklist
1. Patient details 49 50 45 60 50
3.Site/side marking done 49 49 45 60 49
4. All parameters checked 49 49 45 59 49
5. SNDT of Anaesthetist, surgeon & nurse 49 47 44 59 50
Total
Operation Records
1. Patient details 49 50 55 59 50
2.Consultant Name 48 50 53 59 50
3. Date/Time of surgery 42 45 50 56 49
4.Surgery 42 46 51 54 49
5. Pre & Post OP diagnosis 33 37 39 42 37
6.Pocedure/Operation Notes 48 49 55 52 50
7.Post OP care plan 49 50 55 60 50
8.Post OP treatment orders 49 50 55 60 50
9.SNDT of Surgeon 49 49 55 59 50
Total
Death Summary
1.Patient Details 1 0 0 0 0
2. Diagnosis 1 0 0 0 0
3.cause of death 1 0 0 0 0
4. History 1 0 0 0 0
5. Hospital course 1 0 0 0 0
6.Consultant Name,Sign 0 0 0 0 0
7. RMO Name,Sign 0 0 0 0 0
Total
Discharge Summary
1. Patients Details 119 120 120 120 120
2. Diagnosis 119 120 120 120 120
3. Procedures (If Any) 0 1 0 0 1
4. Surgery ( If Any) 49 48 59 63 52
5. Past History 119 120 120 120 120
6.Examination/Findings 119 120 120 120 120
7. Course in hospital (operation notes) 119 120 120 120 119
8. Investigation(Lab, Radiology, others) 119 120 120 120 120
9. Condition at discharge 119 120 120 120 120
10. Advice on discharge 119 120 120 120 120
11.Follow up Advice 119 120 120 120 120
12.when to obtain urgent care is mentioned 119 120 120 120 119
13.Proper Name & sign of Doctor 98 112 118 117 103

AUDITOR NAME AND SIGN: Archana Chouhan

JUN Total JAN FEB MAR APR MAY JUN Total

119 719 120 120 120 120 120 120 720

91 480 74 72 81 83 81 91 482
53 352 64 71 52 53 63 53 356
120 720 120 120 120 120 120 120 720
120 720 120 120 120 120 120 120 720
120 715 119 118 120 120 120 120 717
34 201 38 39 34 31 27 34 203

120 719 120 120 120 120 120 120 720

116 715 120 120 120 120 120 120 720

116 715 120 120 120 120 120 120 720
114 693 116 118 118 118 116 118 704
105 649 111 114 111 113 113 113 675
59 327 60 111 104 105 103 111 594
111 626 99 114 104 110 110 119 656
116 708 119 120 120 119 120 120 718
96 512 84 119 120 116 118 117 674
110 642 103 120 120 120 120 120 703
81 465 85 116 119 117 113 112 662
81 459 77 116 94 117 113 120 637
113 627 89 120 120 120 120 120 689
114 705 119 120 120 120 120 120 719

120 720 120 120 120 120 120 120 720

120 720 120 120 120 120 120 120 720
113 591 120 120 120 120 120 120 720
120 704 120 120 120 120 120 120 720
120 720 120 120 120 120 120 120 720
120 720 120 120 120 120 120 120 720

22 138 24 19 20 25 28 22 138
22 138 24 19 20 25 28 22 138
22 138 24 19 20 25 28 22 138
22 138 24 19 20 25 28 22 138

120 720 120 120 120 120 120 120 720

111 692 120 119 120 120 119 120 718
117 684 119 119 119 118 118 119 712
27 192 34 37 27 32 35 27 192

118 706 120 119 120 120 120 120 719

119 683 120 119 119 118 99 119 694
118 683 120 117 120 119 100 119 695

120 710 118 113 120 119 120 120 710

120 634 117 113 120 119 120 120 709
4 17 117 113 120 119 120 120 709
120 710 118 113 120 119 120 120 710

1 11 6 6 9 8 7 4 40
1 11 6 6 9 8 7 4 40

120 720 120 120 120 120 120 120 720

120 720 120 120 120 120 120 120 720
119 719 120 120 120 120 120 120 720
15 56 0 0 28 7 7 15 57
119 678 109 120 114 112 115 119 689

35 247 51 40 43 32 46 35 247
34 243 51 40 43 32 46 35 247
34 242 51 40 43 32 46 35 247

34 244 51 40 43 32 46 35 247
33 242 51 40 43 32 46 35 247

35 246 51 40 43 32 46 35 247
35 243 51 40 43 32 46 35 247
34 242 51 40 43 32 46 35 247
35 247 51 40 43 32 46 35 247
34 244 51 40 43 32 46 35 247
35 236 51 40 43 32 46 35 247

31 181 24 33 34 27 32 31 181
31 181 24 33 34 27 32 31 181
31 179 24 33 34 27 32 31 181
30 180 24 33 34 27 32 31 181

31 190 34 26 28 34 37 31 190
13 67 25 18 23 32 29 27 154
30 187 34 26 28 34 37 30 189
15 111 32 24 16 28 33 23 156
27 177 34 26 28 34 37 31 190

54 317 49 50 55 60 50 54 318
53 301 49 50 55 60 50 54 318
53 300 49 50 55 60 50 54 318
53 313 48 49 55 60 50 53 315
54 273 49 50 55 60 50 54 318
50 273 49 50 55 60 50 54 318
53 312 49 50 55 60 50 54 318

31 182 24 34 34 27 32 31 182
31 181 24 34 34 27 32 31 182
31 181 24 34 34 27 32 31 182
31 182 24 34 34 27 32 31 182
30 181 24 34 34 27 32 31 182
30 180 24 34 34 27 32 31 182
30 181 24 34 34 27 32 31 182
30 180 24 34 34 27 32 31 182

16 130 27 16 31 24 16 16 130
16 125 26 16 31 24 16 16 129
14 106 27 16 31 21 16 16 127

54 308 49 50 45 60 50 54 308
54 308 49 50 45 60 50 54 308
53 305 49 50 45 60 50 54 308
54 307 49 50 45 60 50 54 308

54 308 49 50 45 60 50 54 308
54 296 49 50 45 60 50 54 308
54 308 49 50 45 60 50 54 308
54 307 49 50 45 60 50 54 308
54 308 49 50 45 60 50 54 308
54 308 49 50 45 60 50 54 308
52 292 49 50 45 60 50 54 308
54 302 49 50 45 60 50 54 308
54 308 49 50 45 60 50 54 308
54 303 49 50 45 60 50 54 308

54 301 49 50 45 60 50 54 308
54 304 49 50 45 60 50 54 308
54 302 49 50 45 60 50 54 308
54 306 49 50 45 60 50 54 308

54 307 49 50 45 60 49 54 307
54 307 49 50 45 60 49 54 307

54 308 49 50 45 60 50 54 308
54 306 49 50 45 60 50 54 308
54 305 49 50 45 60 50 54 308
53 302 49 50 45 60 50 54 308

54 317 49 50 55 60 50 54 318
54 314 49 50 55 60 50 54 318
51 293 48 50 55 60 50 54 317
50 292 49 50 55 60 50 54 318
30 218 49 50 55 60 50 54 318
54 308 49 50 55 60 50 54 318
54 318 49 50 55 60 50 54 318
54 318 49 50 55 60 50 54 318
54 316 49 50 55 60 50 54 318

0 1 1 0 0 0 0 0 1
0 1 1 0 0 0 0 0 1
0 1 1 0 0 0 0 0 1
0 1 1 0 0 0 0 0 1
0 1 1 0 0 0 0 0 1
0 0 1 0 0 0 0 0 1
0 0 1 0 0 0 0 0 1

120 719 119 120 120 120 120 120 719

120 719 119 120 120 120 120 120 719
0 2 0 1 0 0 1 0 2
54 325 49 48 59 63 52 54 325
120 719 119 120 120 120 120 120 719
120 719 119 120 120 120 120 120 719
120 718 119 120 120 120 119 120 718
119 718 119 120 120 120 120 120 719
120 719 119 120 120 120 120 120 719
120 719 119 120 120 120 120 120 719
120 719 119 120 120 120 120 120 719
120 718 119 120 120 120 120 120 719
100 648 113 120 120 120 120 120 713
 Cases
Diseases
Acute diarrheal Reported
disease 4402
Food poisoning 2680
Dengue 1405 5000
Chikungunya 610 4500

Viral Hepatitis A 500 4000

3500
Jaundice 207 3000
Malaria 2428 2500
2000
1500
1000
500
0
1 2 3
 Diseases
Cases Reported

1 2 3 4 5 6 7 8