Change in Completeness of Medical Records After Nabh Process in A Teaching Hospital Farooqui Iqbal Ahmad1, Prasad D. Pore2, Doke P. P.2, Kumar Amit1 1Post Graduate Student, Department of Community Medicine, Bharati Vidyapeeth Medical College, Pune, India 2Professor, Department of Community Medicine, Bharati Vidyapeeth Medical College, Pune, India Online published on 29 December, 2017. Abstract Introduction Comprehensive medical record is a cornerstone in the quality and efficiency of patient care during hospitalization and in subsequent follow-up visits, as they can provide a complete and accurate chronology of treatments, patient results and future plans for care. An incomplete medical record may reflect a poor and inadequate clinical care. It can also be used to support the allegations of negligence and fraud Purpose To check the completeness of medical record/IPD files in a teaching hospital in Pune. Methods The study was conducted at a teaching hospital attached to a medical college in Pune. Activities pertaining to NABH accreditation were conducted in October 2015 which were considered as intervention. A comparative study was done during January to May 2016 on the IPD records of September (Pre intervention) and December 2015 (Post intervention). Sample size was calculated to be 170 in each group. The IPD records of Pre and Post intervention period were analysed on the parameters in structured checklist. Data was analysed statistically by simple proportions using SPSS v20. Results As compared to the 78.75% completeness of IPD records in September, a significant increase of to 87.75% (p-value <0.01) was observed in December. Department wise participation was seen maximum of medicine (65/170 i.e. 38.24%) in September and of paediatrics (49/170 i.e. 28.82%) in December. Department wise average completion per cent of IPD records was best seen in psychiatry (97.06/100) in September and in December it was of ENT department (95.00/100). Maximum change was observed in ENT department. Conclusion Few activities pertaining to accreditation of the hospital to NABH improves the completeness of medical records. Novelty There is a paucity of existing data regarding the completeness of IPD records and measures to improve it. Top Keywords Completeness, Intervention, Medical Records, NABH. Top |