Commentary: Internal audit for assessment and improvement of quality of medical records

The importance of maintaining detailed and correct medical records can never be emphasized enough. In the increasingly litigious society, not keeping accurate medical records can spell doom for the health care facility. In the medicolegal context, an accurate and contemporaneous medical record helps prove the integrity of the health care professional. Apart from this, medical records show the thought process behind and support clinical decision-making. They can help in policy-making and are invaluable for research. Without clear and accurate medical records, data collection and analysis would be a difficult task.

Medical records are important for patient care. They maintain continuation of care and facilitate communication among various specialist health care professionals. Meticulously maintained medical records promote transparency and accountability. They also reflect patient satisfaction. Thus, maintaining and improving the quality of medical records should be of top priority for any health care organization.

However, this is not an easy task and requires continuous monitoring. Internal auditing is a way of monitoring and detecting errors and deficiencies. Vaghmare, et al.[1] have shown that internal audit can effectively improve the quality of medical records. They used a five-pronged multimodal intervention for the audit which included a near real-time audit and feedback. They noted consistent improvement every month for three months with the score improving from 57.93 ± 24 to 99.07 ± 4.49 out of 100. In a study by Azzolini et al.,[2] a similar strategy of auditing case records was done where a 48-point grid was used to assess the quality. They also noted improvement in the quality of medical record keeping. They concluded that internal audit is a necessary activity of any health care organization. It can assess the quality of clinical care, maintain high standards of professional performance and can thus help the organization achieve its objectives.

In another similar study, a unique CRABEL score was used to check the completeness of surgical notes.[3] The authors were surprised to see that even the most basic information, such as the name of the admitting doctor or date of admission and discharge, was sometimes found missing. The CRABEL score was seen to be effective and easily reproducible. The improvement, however, lasted only for three cycles and repeated auditing cycles were advocated to ensure continuous high quality.

The decision of the authors of this study to audit trauma cases shows careful planning.[1] Generally, the topic or theme for the audit should be of great clinical importance, with significant consequences, and should be easy to collect information and analyze it.[4] The personnel audited should have a major role to play in dealing with the chosen clinical theme. And although the authors did not address treatment-related errors, they were able to show 100% improvement in documentation. Improved documentation can also lead to improvement in clinical care.

Internal audit is a necessary activity to assess the quality of clinical care and maintain high professional standards. Every health care organization should strive for better maintenance of health records. Together with other quality control measures, an internal audit should become an integral part of the health care organization.