Volume 7 | Issue -2
Volume 7 | Issue -2
Volume 7 | Issue -2
Volume 7 | Issue -2
Volume 7 | Issue -2
Introduction: Medical records are crucial for meeting legal and professional healthcare standards and are key performance indicators for accreditation. Comprehensive records ensure patient identification, diagnosis validation, and support care documentation. Accurate, complete records ensure continuity of care, patient safety, and effective communication among healthcare professionals, while also providing legal protection and aiding in financial, educational, and research purposes. Materials and Methods: This study examines 640 inpatient records from Shri B M Patil Medical College Hospital, Vijayapura, India, for 6 months of 2023. It evaluates documentation completeness and accreditation compliance in 160 records each from Surgery, Obstetrics and Gynaecology, Orthopaedics, and ENT departments using systematic random sampling and a deficiency checklist. Results: Analysis revealed varying completeness in medical records across departments. There was high completeness in OPD Registration and Discharge/Death Summary (98.8%) and Anaesthesia Records (96.3%). Surgery Consent (75.6%) and Investigation Reports (72.5%) showed lower completeness. Essential elements like history sheets, doctor’s orders, and nurse’s records show 6.3% to 11.9% incompletion. Conclusion: Accurate medical records are vital for patient care and hospital management, enhancing continuity of care and informed decision-making. Regular audits, staff training, adequate paramedical support, and key performance indicators are essential for maintaining quality. Improving communication and adopting electronic records can further enhance documentation. Findings were shared with hospital administrators.