Medical recored Completness N=50
120
100 100
96 98
88
80 84
62
60
58
40
28
20
0
Physician Vital sign Progress Order NCP MAR DPS CPR
notes Sheet note Sheet
Performance ( %)
The highest performer Patient Card (Physician notes) present and all entries signed from
surveyed 50/50 (100%), So it is very good experience I would be thanks all physian and
Integrated Emergency surgeon officers in IPD ward Adet Primary Hospital 1 st quarter, 2017 E.C
on the other hand discharge planning and summary – present and signed, Progress note –
documented at least once a day throughout the hospital stay & order sheet – Present and revised
daily (N=50) 28%, 58% and 84% respectively. This showed that there is poor continuity and
quality of care of inpatient service. Therefore all physian and Integrated Emergency surgeon
officers in IPD should be focused in discharge planning and summary – present and signed,
Progress note – documented at least once a day throughout the hospital stay & order sheet –
Present and revised daily.
Inpatient ward clinical pharmacy service should be implemented in Adet hospital 24 hr a day, 7
day a week and 365 day a year. But from the above graphs showed that the performance of
Clinical pharmacist recording from surveyed (N=50) 31/50 (62%) which is under question??? Is
there clinical pharmacy service 24hr in the hospital?? Clinical pharmacists manage medication
therapy in direct patient care settings and they assess patients, recommend treatment plans to
maximize benefits and minimize risks. Therefore Clinical pharmacist recording charts present
and signed in all inpatient wards patient charts
Action plan for Medical Recorded Completeness
No Identified gaps Action to be taken Responsible bodies Timeliness
1 Vital sign BP, PR, RR, To, pain score and Spo2 not Vital sign BP, PR, RR, To, pain score and IPD case manager Metron, From 30/01/2017 E.C
appropriately recorded Spo2 should be appropriately recorded IPD case team leader and all
Nurse in the ward
2 Progress note did not documented at least Progress note must be documented CCO, IPD case manager From 30/01/2017 E.C
IESO, Physian, Metron, IPD
once a day throughout the hospital stay at least once a day throughout the
case team leader
hospital stay
3 Order sheet did not present and revised Order sheet should be present and CCO, IPD case manager From 30/01/2017 E.C
IESO, Physian, Metron, IPD
daily revised daily
case team leader
4 Nursing Care Plan did not revised at least Nursing Care Plan must be revised IPD case manager, Metron, From 30/01/2017 E.C
IPD case team leader all Nurse
daily; V/S taken at least QID for all at least daily; V/S taken at least QID
in the ward
admitted patients for all admitted patients
5 Discharge planning and Summary did not Discharge planning and Summary CCO, IPD case manager From 30/01/2017 E.C
IESO, Physian, Metron, IPD
present and signed must be present and signed
case team leader and all Nurse
in the ward
6 Clinical pharmacist recording did not Clinical pharmacist recording must CCO, Pharmacy From 30/01/2017 E.C
charts present and signed be charts present and signed
head, IPD case
manager and all
pharmacy in IPD
ward
50 medical records completeness chart Re audited are listed in the checklist
Eight MRC Physian Vital Progress Order Nursing Medication Discharge Clinical
minimum notes sign note Sheet Care Administratio planning and pharmacist
Elements Plan n Record Summary recording
MRN Yes No Ye No Yes No Yes No Yes No Yes No Yes No Yes No
s
121962
122295
106896
118964
122329
030308
122353
054554
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116829
105390
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109830
122515
119899
122536
122540
122880
013330
008490
122929
115476
522948
123070
123818
030827
123841
123821
082539
120023
123874
088316
123916
080682
123922
052286
123943
072667
123952
086976
123955
123995
063582
124005
045526
124050
123990
090387
098660
124041
124092
124133
124129
042973
124139
065255
