Format F/001/MRD
Audit - Medical Record Completion
MRN: IP No.: OPEN FILE CLOSED FILE
DOA: DOD: / / / / / / / / Remarks
Diagnosis:
Y N NA Y N NA Y N NA Y N NA
Initial Assessment is done by Doctors
immediately/within stipulated time.
Plan of care within 24 hours
Allergies on admission & treatment noted
(Form 7 to 1593, & 99a)
Current Medications noted
ASSESSMENTS
Pain Assessment by Medical & Nursing
Educational, Functional, Learning
Assessment is done by Medical & Nursing
Patient Family Education is done
Daily Pain Scoring
Initial Assessment done by Nursing within
2 hours
Nutritional Assessment is done
Authorized abbreviations & symbols used
Daily Reassessments are done
All Consents are Complete
(Form 20-31b)
CONSENTS
No abbreviations (Diagnosis, Procedure)
Risks, benefits, complications, and alter-
natives of Anesthesia & Surgery mentioned
Patient’s / Relative’s / NOK signature
Clinician & Witness’s signature
Preoperative assessment is documented
before anesthesia or surgical treatment.
(F 33,40,48,&55a)
Date, Time & Sign of Surgeon & Nurse
SURGERY
Preoperative Time Out is done
Intra & Post Op monitoring (Anesthesia)
Blood Loss & Specimen details on OT Notes
Authorized abbreviations & symbols used
Pre & Post Operative Diagnosis
Doctor notes date, time, sign, Name & ID
PROGRESS
Nurses notes date, time, sign, Name & ID
NOTES
Authorized abbreviations & symbols used
Daily Pain Assessment
Discharge Instructions & Care given
Medication names in CAPITAL/Legible
Allergies noted & signed
CHART (F 91)
MEDICATION
Authorized abbreviations & symbols used
Dose, Strength, Frequency, Route, Date &
Time
Administration verified by Second Nurse
Monitoring done by Clinical Pharmacist
F 92 Clinical Chart Complete
Blood Transfusion Consent
TRANSFUSION
Blood Transfusion start & end time noted
BLOOD
Vitals monitored frequently in process
Adverse reactions noted (if any)
Doctor’s Signature
Revision 2
Format F/001/MRD
Audit - Medical Record Completion
OPEN FILE CLOSED FILE
/ / / / / / / / Remarks
Y N NA Y N NA Y N NA Y N NA
In-house Transfer form
All Investigation Reports (Original / Copy)
Planned Discharge
No ABBREVIATIONS in DIAGNOSIS &
DISCHARGE SUMMARY
PROCEDURE
ICD Coding (Diagnosis & Procedure)
Investigation findings
Details of Procedures performed
Medications given
Instructions regarding how & when to
obtain urgent care
Follow up & Medication Advice
Treating Consultant’s signature
General Consent is signed by relative
(Admission Form)
Clinical Pathways - Complete date, time,
sign, Name & ID
Physiotherapy Assessment - Complete
date, time, countersigned, Name & ID
(If Applicable)
ICU Daily Goals Checklist
OTHERS
Restraint Assessment & Consent
Consultation Referral Sheet
Safety First
Diabetic Chart
Acknowledgement form
MLC intimation copy & stamp
Death Intimation Certificate
Form 4 Cause of Death – ICD Coding
Death Summary
Record Review by:
Sign & ID
Audited by: Verified by: Authorized By:
(Name) (Consultant Incharge) (Medical Administration)
Revision 2
