A Study to assess the completeness of Medical Discharge Summaries at Sooriya Hospital in Chennai
Hospital deals with the life and health of their patients.
Good medical care also relies on good record-keeping. Without accurate, comprehensive up-to-date and accessible case notes, medical personnel may not offer the best treatment. Good records care also ensures the hospital’s administration run smoothly. Unneeded records are transferred or destroyed regularly. Keeping
storage areas clean and accessible and key records can be found quickly, saving time and resources. Records also provide evidence of the hospitals accountability for its actions and they form a key source of data for medical research, statistical reports and health information
systems. A medical record is a systematic documentation of a
patient’s medical history and future care for medico-legal use. A poor medical record maintenance can negatively affect patient care and safety. This study aims to assess the proper maintenance of medical records in Sooriya Hospital, a tertiary care teaching hospital attached to a Medical college. Methods: This cross-sectional study was
conducted by analyzing first 150 discharge summaries of patients discharged from March 1, 2011 from various specialties of a tertiary care hospital excluding medico legal cases. The discharge summary
format of the hospital was taken as the standard and evaluation for adequacy of history and others parameters entered was assessed. Descriptive statistics were used to analyze various statistical
discrepancies. This study aims to assess the adequacy of medical records by the professionals, prepared by the hospital and to introduce the concept of hospital records management and the context within which hospital records management programmes operate.
Wikipedia. Medical record. [Online]. [Cited 19 May 2009]; Avialable
from URL: http://en.wikipedia.org/wiki/Medical_records
Rao P. Andrei A, Freid A , Gonazalez D, Shine D. Assessing quality and
wffeciency of discharge summaries. Am J Med Qual 2005 Nov-
Van Walraven C,Rokesh E. What is necessary for high-quality dischare
summaries? Am J Med Qual 1999 Jul-Aug; 14(4):160-9.
Joint Commission on the Accreditation off Healthcare Organizations.
Standard IM.^.10,EP 7 Website. [Online]. [Cited 31 Mar 2008];
Available form URL;
Hayrinen K, Saranto K, Nykanen P, Definition structure content, use and
impacts of electronics health records: a review of the research literature.
Int J Med Inform 2008 May; 77(5):291-304.
Myres Js, Jaipaul CK, Kogan JR , KreKun S, Bellini LM, Shea JA.
Myres JS , Jaipaul CK kogan JR ,Krekun S, Bellini LM ,Shea JA.Acad
Med 2006 Oct; 81(10 Suppl):S5-8;
D V NN,Rjavelu P,Rajagopalan A . Pre-formated written discharge
summary system. CMAJ quality assurance in the emergency
department,Int J Emerg Med 2008 Dec; 1(4):321-5;
Van Walraven C,Weinberg AL.Quality assessment of a discharge
summary sytem. CMAJ 1995 May 1; 152(9):1437-42.
Young As,Sullivan G,Burman MA,Brook RH .Measuring the quality of
outpatient treatment 1995 MAY 1; 152(9): 1437-42.
Tsai J, Bond G. A comparison of electronic records to paper records in
mental health centers. Int J Qual Health Care 2008 Apr; 20(2):136-3.
Hippissley-Cox J , Pringle M, Cater R, Wynn A ,Hamesmersley V,
Coupland C, Hapgood R, et al. The eletroonic patient record in primary
record in primary care-regression or progression? A cross sectional
study. BMJ 2003 Jun 28; 326(7404):1439-43.
Lorenzi Nm,Kouraoublai A Detmer DE, Bloomroson M. How to
successfully select and implement electronic health record (EHR) in
small ambulatory practise settings. BMC Med Inform Decis Mak 2009
Feb 23; 9:15.
Medical errors the scope of the problem, agency for health care research
agency for health care research and quality (Website) assessed
September 28 2009.
Secondary data collected from the Sooriya hospital files. 2012.
Zeshan Pervez,Asad Masood Khattak and Sungyoung Lee (2010),”
Chord based Identity management for E- Health care Cloud
Joint commission on accreditation of health care organizations. 2005,
National patient safety goals.http://www.jcaho.org/accredited+
Jack,B.W.,Chetty,V.K.,Anthony,D.et al 2009 Feb 3. A reengineered
hospital discharge program to decrease re hospitalization.
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