Medical File Auditing and Its Effect on Performance Indicators

Abstract

The process and products of documenting clinical care occupy a critical intersection among the diverse domains of patient care, clinical informatics, workflow, research, and quality (Rosenbloom et al., 2011). The aim of the present study was to conduct assessment of medical files documentation in Obstetrics and Gynaecology department 1st unit Ain Shams University hospital, before and after medical files auditing, review and awareness of residents about documentation importance and effect of documentation on accuracy of some performance indicators. 147 files were included in the study before residents’ awareness, other 147 files were included after awareness. The second sample was divided in two stages and reviewed after residents’ awareness. 1st and 2nd stage were reviewed after residents’ awareness conducted at 16th July 2013, and 8th October 2013 respectively. All files were revised against medical checklist quoted from the American Medical Association/Specialty Society Medical Liability Project. It has been shown that some items have been improved after residents’ awareness, while others weren’t improved. The study showed the average of all files completeness was 49.4% before awareness. It has become 57.3% after 1st awareness. After the 2nd awareness, it has become 51.2%. The total completeness after 1st and 2nd awareness was 54.3%. Performance indicators couldn’t be estimated due to deficient data before and after audit. It’s recommended to establish the role of Medical Record Review Committee and to conduct regular medical files auditing including medical files systematic review against explicit criteria and implementation of change, taking action to improve care, and monitoring to sustain improvement. Every time an audit cycle is completed, there should be further improvement in patient care (Salomon et al., 2010).