Audit of paediatric residents' medical records

Summary Background The quality of the information contained in a medical record is dependent on the knowledge and skills of the doctor. The auditing of medical records is one of the items included in the competency evaluation of residents at the Department of Pediatrics, Prince of Songkla University ( PSU ), Thailand. Objectives To determine the percentages of ‘not met’ and ‘not acceptable’ charts written by residents, which parts of the residents’ writing required improvement and associated factors. Methods The charts of four newly admitted cases at each ward were selected non‐randomly by attending staff for bi‐weekly audit. The audit form comprised 15 components, with each component scored as ‘met’ or ‘not met’. Medical records with more than two ‘not met’ items were categorised as ‘not acceptable’. Results From September 2012 to October 2013, a total 506 in‐patient medical records written by PSU paediatric residents were reviewed. The components identified as having the highest rates of ‘not acceptable’ completion were ‘initial investigations’ (5.3%), ‘summary of investigations’ (4.5%) and ‘progression of clinical conditions’ (4.3%). The reasons for a ‘not acceptable’ evaluation were ‘incomplete documentation’ (65.0%), ‘lack of follow‐up’ (26.7%) and ‘incorrect clinical reasoning’ (8.3%). Using logistic regression analysis, the charts of patients from the chronic illness wards were found to be most significantly associated with the ‘not acceptable’ rating. Residents need skills and knowledge when completing patient recordsConclusions Residents need skills and knowledge when completing patient records, and attending staff should be aware that it is their responsibility to ensure that residents complete documentation fully and correctly.