Clinical Audit on Record Keeping Standards at a Specialized Out-patient Child Psychiatry Service in Sri Lanka

Abstract

Background: Accurate and up-to-date patient records are essential to ensure high standards of clinical care and achieve professional standards from a medico-legal perspective. Objectives: This clinical audit aimed to investigate record keeping practices including documentation of the evaluation, execution of management plan and confidentiality of record organization. Methods: Paper-based clinical records of 250 outpatients were reviewed randomly using an evaluation form. Results: Although the confidentiality of record organization and execution of the management plan were satisfactory, serious concerns were identified regarding the documentation of evaluation. Conclusions: The audit showed current record-keeping deficiencies, highlighting the need for record-keeping procedures and policies.

Keywords

• medical records
• quality standards
• audit