Departmental case notes audit: A quality assurance measure in a changing organizational climate

Mansoor Dilnawaz, Nadia Iftikhar

Abstract


Background A clinical audit measures practice against standards. It aims to deliver safe and quality care through a systematic approach. The research focuses on the question, “what is the right thing to do?” whereas the audit aims to see if we are doing the right thing in the right way.1-4

 

Aims and Objectives To highlight the importance of meticulous record keeping in clinical case notes.

 

Methods 20 case notes were examined from the dermatology ward. The method of data collection was retrospective. The basis of proposal was local guidelines. The audit type was Process. The standard set was “100%.

 

Results The result showed 75% compliance with our local guidelines in the analyzed case sets.

 


Keywords


Clinical audit, quality, safety

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