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- W2740086265 abstract "Auditing the Medical Record is maintained by 'proper management of health records and accurate, comprehensive record-keeping. Ensuring quality of patient care documentation can be attainted through its completeness in its medical record. This parameter is essential in the continuity of care rendered by different health professionals in the hospital. In return, the medical records can promote safety and effective communication with the health care team. Purpose: This research was conducted in a government tertiary hospital in Riyadh which caters Maternity and Child Care services. The estimated bed capacity of this hospital is 500. This study evaluated the completenessof the content of medical record utilizing the Patient Medical Record Content ( PMRC ) Standards of the hospital. Method: Quantitative descriptive research design was used in conducting this study. The data has been collected from four (4) clinical unitsnamely, gynecological, post-partum, pediatric, and antenatal units in a selected government tertiary hospital with 310 beds specializing in maternity and pediatric care, A purposive sampling with 10% set criterion has been used to reach the target medical records for auditing. The tool that was used in auditing the medical record is PMRC Standards of the hospital. The study was conducted between December 2014 and January 2015. Data were analyzed using the Statistical Package for Social Sciences ( SPSS ) windows, version 16. Result: Each clinical unit was evaluated using PMRC Standards Tool of the hospital. In the four (4) units, the total number of medical records audited were as follows: Gynecological Unit ( n= 3 ); Post-Partum ( n= 14 ); Pediatric ( n= 6 ); Ante-natal ( n= 5 ). Twenty eight ( n= 28 ) medical records have shown that they have almost all complete content except from items like: Protocol Order, Braden Scale, Patients' Bill of Rights Forms. In items that were incomplete, the following forms were noted: Echo Reports, Radiology, Social Worker, Fall Assessment and Re-assessment, Nursing Care Plan, ER Assessment Sheet, Medication Record, Therapeutic Nutrition forms, Nurses' Progress Notes, History and Physical Examination, Nursing Admission Assessment, ER Nursing Assessment Sheet, Pain Management , Patient Family Health Education. Conclusion: In this study, there were missing or incomplete important items in the medical record. Prioritizing medical records in terms of its completeness and maintaining compliance to standards can help a hospital promote safety , better collaboration and proper communication. The use of data in the medical record will lead to quality , effective nursing and medical care. In future studies, it is recommended that other criteria not only completeness can be used in evaluating medical records." @default.
- W2740086265 created "2017-08-08" @default.
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- W2740086265 date "2015-01-01" @default.
- W2740086265 modified "2023-09-24" @default.
- W2740086265 title "Medical Record Audit in Clinical Nursing Units in Tertiary Hospital" @default.
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