Clinical Audit on Accuracy and Timeliness of Patient Admission Notes to Improve Quality of Care at a Tertiary Care Hospital

Abstract

Background: The accurate and timely completion of patient admission notes is crucial for high-quality patient care and effective communication among healthcare providers. In the Pulmonology ward, where patients with respiratory conditions receive specialized treatment, comprehensive and prompt documentation of admission information is paramount. The complexity of these conditions and potential for acute exacerbations make accurate and timely documentation even more critical for guiding appropriate interventions and ensuring patient safety.

Methodology: This uni-disciplinary audit reviewed prospective admission records and associated data for each patient over one month, with a sample size of 75 patients. The initial audit was conducted from June to July 2023 in the Pulmonology ward of Bahawal Victoria Hospital, Quaid-e-Azam Medical College Bahawalpur. Following initial audit recommendations, a proforma on patient admission notes with pre-written variables was created and explained to house officers and postgraduate residents. A subsequent re-audit was conducted from September to October 2023 to compare results with the initial audit.

Results: The audit findings indicated a need for improvement in the timeliness of patient attendance and the documentation of initial assessments, vital signs, and treatment plans. The re-audit suggested improvements in patient attendance timeliness and initial assessment with vital sign recordings. However, the treatment chart signatures, and postgraduate resident stamps still needed improvement.

Conclusion: Implementing the suggested recommendations can enhance patient care and ensure compliance with established protocols. Regular monitoring and follow-up audits are recommended to evaluate the effectiveness of the changes.