ABSTRACT:

Introduction: 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 Victoria 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, 2009 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 other parameters entered was assessed. Descriptive statistics were used to analyze various statistical discrepancies.

Results: Patient’s condition at discharge was missing in 86 (66.15%). Patient’s address was missing in 21 (16.1%) cases. Almost all the discharge sheets lacked mailing address. Total 96 (73.8%) summaries had use of abbreviations for diagnosis. Age and sex were missing in 1 (0.76%) case. Doctor’s signature was illegible in 103 (79.3%) and missing in 2 (1.5%) summaries. Doctor’s name and their level/position were missing in 118 (90.76%) and 125 (96.1%) respectively. Total 126 patients (96.9%) were not given any instructions on discharge.

Conclusions: The discharge summaries analyzed were seen to be inadequate especially in documenting the course during hospital stay, condition at discharge, appropriate instructions and the treating physician’s details. These can probably be addressed by introducing electronic medical records if feasible. Otherwise, the discharge summary should be standardized and doctors should be trained to write legible, complete discharge summaries.

Keywords: discharge summaries, hospital, records, Patients, follow up

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