A Study to Assess the Completeness of Medical Discharge Summaries at Sooriya Hospital in Chennai

Hospital deals with the life and health of their patients. Good medical care also relies on good record-keeping. Without accurate, comprehensive up-to-date and accessible case notes, medical personnel may not offer the best treatment. Good records care also ensures the hospital’s administration run smoothly. Unneeded records are transferred or destroyed regularly. Keeping storage areas clean and accessible and key records can be found quickly, saving time and resources. Records also provide evidence of the hospitals accountability for its actions and they form a key source of data for medical research, statistical reports and health information systems. 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 Sooriya 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, 2011 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 others parameters entered was assessed. Descriptive statistics were used to analyze various statistical discrepancies.
This study aims to assess the adequacy of medical records by the professionals, prepared by the hospital and to introduce the concept of hospital records management and the context within which hospital records management programmes operate.