• Users Online: 302
  • Print this page
  • Email this page
Year : 2019  |  Volume : 28  |  Issue : 1  |  Page : 80-83

Audit of medical records keeping at a Nigerian geriatric clinic

New Jerusalem Road, Bonny, Rivers State, Nigeria

Correspondence Address:
Dabota Yvonne Buowari
New Jerusalem Road, Bonny, Rivers State
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1115-2613.278620

Rights and Permissions

BACKGROUND: A medical record also known as health chart is the written health information about a patient or clients and is always opened whenever a patient or client visits a health facility. There are different types of medical records and it may be problem based or patient based; paper based or electronic. It enhances continuity of care; source of communication between healthcare professionals, as aides de memoire and it is a legal document. OBJECTIVE: To compare the medical records keeping with reference standards. METHOD: This is a prospective clinical audit, was conducted in a Nigerian Nursing Home for the elderly. The medical record keeping was compared with the generic standards of medical record keeping of the Health Informatics Unit of the Royal College of Physicians. Two clinical audit cycles were performed. RESULTS: At the first clinical audit cycle only the third standard was 50%, others were zero. At the second clinical audit cycle there was improvement and 100% increase in standard 1, 3, 4 and 5, with 10% increase in standard 2. Paper based medical records are kept at the nursing home. Most of the residents do not know their age as their birth dates was not recorded. There were 30 residents at the nursing home when the clinical audit was conducted. CONCLUSION: Initially, the medical record keeping was below standard but with the clinical audit there was improvement. Clinical audit is important in medical practice in comparing the practice with standards.

Print this article     Email this article
 Next article
 Previous article
 Table of Contents

 Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
 Citation Manager
 Access Statistics
 Reader Comments
 Email Alert *
 Add to My List *
 * Requires registration (Free)

 Article Access Statistics
    PDF Downloaded53    
    Comments [Add]    

Recommend this journal