Inpatient Medical File Audit
ID: BCMCH/MRD/OFORM-0001  | BCMCH   IP File Audit  from the year 2018. This audit has to be done by each department after discharge before the file is send to the MRD. Validation of the same is done on random basis by the quality department. For guidance on the minimum requirements of documentation refer to the BCMCH Manual at home.bcmch.org> NABH> NABH Departmental Manuals 2019 > Index number no BCMCH-MAN-0082 Clinical guidelines Manual.
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Date of entry *
MM
/
DD
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YYYY
Department *
UHID *
Time taken for Initial Assessment by Physician after admission. *
(It is the time initial assessment calculated from the documented time of Patient arrival to the bed recorded by  Nurse /Physician.) For details of the policy refer to home.bcmch.org> NABH> Hospital Policies > Index number no 7 BCMCHPOL1001.05 Policy on assessment and reassessment.
Documentation  of Care Plan by Physician *
( From Admission Notes after Patient Arrival to Ward/Bed ) Refer to NABH 4th Edition standard AAC4ghi, AAC5cm COP15g, PRE3d  for requirements.
Desired Outcome ( Prognosis of Patient at arrival) documented by Physician. *
Refer to NABH 4th Edition standard AAC4h for requirements.
Signed, Named, Dated ,Timed  at Initial Admission Notes entry by Physician *
Check which ever is available, if sign, name, date and time is not available select "None"
Required
Care plan counter signed by Doctor in charge *
Refer to NABH 4th Edition standard AAC4i for requirements.
Medication orders on Drug sheet : written in CAPITAL letters on admission. *
As per the MCI norms All prescriptions should be in CAPITALs. Refer to NABH 4th Edition standard MOM 4c & 4g for requirements.
Medication orders on Drug sheet : Written in Generic completely on admission . *
As per the MCI norms All prescriptions should be in Generic. Refer to NABH 4th Edition standard MOM 4c & 4g for requirements.
Medication orders on Drug sheet : Has used Signed, Named Dated & Timed *
Refer to NABH 4th Edition standard MOM 4c & 4g for requirements.
Time taken for Discharge *
This time is calculated from the time of Discharge Notification by the consultant to the time the patient has actually left the bed. Refer to NABH 4th Edition standard AAC 13 and AAC 14.
Legibility of Notes at Admission.
Clear selection
Completeness of Surgical Safety Checklist *
Refer to NABH 4th Edition standard COP 7c, COP 15d for requirements. (Select NOT APPLICABLE if there is no surgery done)
Completeness of Consent Form(s) *
Refer to NABH 4th Edition standard COP7d, COP8d.e.,COP10d, COP13b, COP14e,COP15c, COP16b, COP20d, PRE2b, PRE4,  for requirements.   (Select NOT APPLICABLE if there is no consent required procedure done)
Critical Value Alert-  Intervention Taken by the Physician is Documented in File *
Whether the critical value and action taken on the same is documented appropriately in the patient record by physician? Refer to NABH 4th Edition standard AAC6g, AAC12i  for requirements.  (Select NOT APPLICABLE if there is no critical value(s) reported for this patient)
Immediate Preoperative Anesthetic Re-evaluation Done just one hour before Surgery. *
Refer to NABH 4th Edition standard COP14d for requirements.  (Select NOT APPLICABLE if there is no surgery done)
Discharge Summary has *
Refer to NABH 4th Edition standard AAC14 for requirements.
Yes
No
Not applicable
Final Diagnosis
ICD Coded
Condition at Discharge
When to Obtain Urgent care (In case of...)
Where to obtain Urgent care (Contact no.)
Entered by Employee Name & ID *
When Quality office validates Prefix QO to Emp Name & ID
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