LAUSR

The primary purpose of medical records is to support patient care. It is a means of communication and secondarily, it is an important medicolegal document. Current standards of clinical records are variable. The aim of this study was to assess the adequacy of case notes in a tertiary care hospital and compare it with that of world standards. 231 case records of inpatients in the general surgery department who were discharged were audited retrospectively. Out of 53 standards analyzed, 7 had 100% compliance. More than 75% of compliance was achieved in 30/53 standards. A significant lapse in record keeping was found in daily entries by doctors, the timing of entries, details of initial assessment, and daily progress notes. Maintaining high-quality clinical record is an important part of our responsibility. Deficiencies show up in formal audits of case records. Regular orientation programs to improve the quality of clinical records and regular auditing of case notes are required to ensure adequacy.