MEDICALAUDIT OF PATIENT'S RECORD OF TOTAL HIP REPLACEMENT IN A TERTIARY CARE TEACHING HOSPITAL

Introduction : Medical records are an important piece of document which ensure quality patients care by lisoning among multiple health care providers apart from helping in obtaining licences and accreditations. Medical audit is a systematic review of medical care in order to identify opportunities for improvement and provide a mechanism for its achievement. Arthroplasty surgeries are skilled procedure requiring meticulous planning and its execution viz-a-viz documentations of care involved to mitigate any litigation. Methodology : The observational retrospective descriptive study of 140 patient's record was done by including 24 questions of standard documentation practice in arthroplasty surgeries after pretesting and validation of check list. Observations : Apart from vitals recording and follow-up advice, none of the parameters were 100% documented leaving scope for improvement. Discussion : Audit is continuous process of improving patient's care and is to be done at regular interval. In arthroplasty surgeries the documentation of every step is necessary for patients care and safeguarding the operating surgeon from future litigations. The place of study been recently commissioned must audit its record in the phase of its development so that better practices could be imbibed in its routine practices. Conclusion : Some of the aspect of record keeping was within the prescribed standard practices but there is scope for improvement