An Audit on Medical health record keeping
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Aim of this audit - improve standards in medical health record keeping across the whole of the DME department. Ensure the standard. To review the current practice of medical health record documentation. To re-examine the general quality of the entries within a patient’s health records, and level of compliance of documenting date, time, name of consultant, signature and correct patient details ( Name, hospital number, DOB). To re-establish the level of completion of our discharge letters, using the correct format and timing of commencing the discharge letter. To ensure the clear documentation of advanced decisions to refuse Treatment, CPR must be clearly recorded in the medical record.
audit , medical record , mental health record