Medical Record Parameters
Total documents examined -
Diagnosis:
Diagnosis:
Diagnosis:
Diagnosis:
Diagnosis:
Diagnosis:
Diagnosis:
MR No.
MR No.
MR No.
MR No.
MR No.
MR No.
MR No.
Score - Ye N
s o
1 (a) Discharge slip
Are info asked for correctly
filled with date and signature?
2 Are name and signature of
consultant entered?
3 Are all relevant
recommendations made?
4 (b) Clinical Chart
Is clinical chart for all the days
present
5 Are TPR, input and output
clearly recorded?
6 Is medication intake
symbolically recorded?
7 Are the name, date and time of
consultation recorded?
8 (c) Case sheet
Is the demographic part filled
properly?
9 Is provisional diagnosis and
final diagnosis written?
1 Is the initial assessment sheet
0 written (C/o, H/o, findings,
investigations, treatment plan
with preventive aspects etc)
completely?
1 Are there detailed review notes
1 by concerned specialist?
1 Are all entries having name,
2 date, time and sign of concerned
person?
1 Are adequate follow up notes
3 written as per instructions?
1 (d) Willingness Certificates
4 Is necessary consents attached?
1 (e) Admission file
5 Is provisional diagnosis written?
1 Are signature and name of
6 admitting doctor recorded?
1 Is care plan, diet mentioned?
7
Investigation
Total documents examined X Y
Score Ye N
s o
1 Is pt adequately investigated or
over investigated?
2 Is pt timely investigated?
3 Are investigation requests
properly filled with the
diagnosis?
4 Is report sent without delay?
5 Are results signed by
pathologist/radiologist/concerne
d specialist?
6 Are investigations repeated as
per suggestion of
pathologist/radiologist?
7 Are result attached to case sheet
and copied down in the
casesheet?
Diagnosis
Total documents examined - X Y
Score - Ye N
s o
1 Is provisional diagnosis done at
the time of admission?
2 Is provisional diagnosis done by
the specialist?
3 Is the provisional diagnosis
justified with findings?
4 Does provisional diagnosis agree
with the final diagnosis?
5 Does final diagnosis agree with
the post mortem findings (where
applicable)
6 Is diagnosis made without
delay?
Treatment
Total documents examined - X Y
Score - Ye N
s o
1 Is given treatment acceptable?
2 Is treatment given without
delay?
3 Is all the details of treatment
recorded?
4 Is treatment within competence?
5 Is the patient treated in the
relevant ward?
6 Is adequate nursing care given?
7 Are bedsores present? (where
applicable)
4 Is the diet commensuration with
1 the disease?
4 Are there adequate and timely
2 cross consultation?
8 Is immediate attention given to
the refer cases?
9 Are there justifiable frequencies
of visits by concerned doctors?
End results
Total documents examined - X Y
Score - Ye N
s o
1 Is the patient transferred to
better experts? (if applicable)
2 Is recovery uneventful?
3 Is the complication justifiable?
(if applicable)
4 Is the patient discharged after
reasonable improvement?
5 Is the discharge summary
indicates the conditions when
urgent care is required?
6 Is enthusiastic life saving
measures taken?
7 Is death justifiable?
8 Is the police intimation form
attached in case sheet (if
applicable)
Rated case
Total no. of case sheets X Y
scrutinized
Score Ye N
s o
1 Is surgery indicated?
2 Is adequate surgery done?
3 Is type of anaesthesia
justifiable?
4 Is the pre aneasthesia checklist
filled?
5 Is is the preoperative and post
operative notes completely
recorded?
6 Is the safe surgery checklist
properly recorded
7 Does preoperative diagnosis
agrees with the final diagnosis?
8 Is there proper document to
justify the shifting of patient
form recovery room to SICU?
9 Is post operative infection
avoided?
1 Is any patient/family education
0 given?
General aspects
Total no. of case sheets X Y
scrutinized
Score Ye N
s o
1 Is admission indicated?
2 Is delay in recommendation of
admission delayed?
3 Is prolonged stay justifiable?
4 Is early discharge prevented?
5 Is unnecessary investigations
avoided?
6 Is the treatment is done as per
the standard procedure/protocol?
