Medical Audit

Does each medical record file contain

Is discharge summary included?

Yes

Are significant findings recorded?

Yes

Are details of procedures
performed recorded?

Yes

Is treatment given mentioned?

Yes

Is Patient's condition on discharge
Mentioned

Yes

Is final diagnosis recorded with
main and other conditions?

Yes

Are instructions for follow
up provided?

Yes

Patient history and evidence of physical
examination is Evident

Is the chief complaint recorded?

Yes

Are details of present illness mentioned?

Yes

Are relevant medical history of family members present?

Yes

Body system review?

Yes

Is a report on physical examination
available?

Yes

Are details of provisional diagnosis
mentioned?

Yes

Is an operation report available? (only if surgical procedure
done)

Does the report include pre-
operative diagnosis?

Yes

Does the report include post-
operative diagnosis?

Yes

Are the findings of the diagnosis
specified?

Yes

Is the surgeon's signature available
on records?

Yes

Is the date of procedure
mentioned?

Yes

Progress notes from admission to discharge

Are progress reports recorded
daily?

Yes

Are progress reports signed
and dated?

Yes

Are progress reports reflective of
patient's admission status

Yes

Are reports of patients's progress
field chronologically ?

Yes

Is a final discharge note available?

Yes

Are pathology, laboratory, radiology
reports available (if ordered)?

Yes

Are all entries dated?

Yes

Are times of treatment noted?

Yes

Are signed consents for
treatment available?

Yes

Is patient identification recorded
on all pages?

Yes

Are all nursing notes signed
and dated?

Yes

Does each medical record file contain

Patient history and evidence of physical
examination is Evident

Is an operation report available? (only if surgical procedure
done)

Progress notes from admission to discharge

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Does each medical record file contain

Patient history and evidence of physical examination is Evident

Is an operation report available? (only if surgical procedure done)

Progress notes from admission to discharge

Dark Mode

Light Mode

Patient history and evidence of physical
examination is Evident

Is an operation report available? (only if surgical procedure
done)