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Patient record rap

Calcutta, Aug. 28: Shortly after bringing doctors under the ambit of the ongoing medical audit, the government today said details of patients admitted to a hospital should be meticulously maintained and will be subjected to surprise checks.

Director of health services Prabhakar Chatterjee said at Writers’ Buildings that patients’ details were not efficiently maintained in state-run hospitals. “Only about 40 to 45 per cent of the instructions on patients’ details are followed. We have given certain parameters to all hospital authorities and asked them to follow them strictly. We should achieve a target of at least 75 per cent. Countries like the UK and the US are very particular about maintaining medical record details of indoor patients,” he added.

Chatterjee also said nurses would be brought under the audit to assess their performance. “We will carry out surprise checks in our hospitals to find out whether our instructions are being followed.”

The health department had found a lacuna in maintaining medical records of indoor patients while preparing the data bank on government doctors. “The doctors will have to change their mindset. Many doctors think our attempt to carry out a medical audit will be a challenge to their professional efficiency. But we are not meaning the doctors are inefficient,” he added.

A patient’s bed ticket must mention the date of admission, immediate and final diagnosis, length of stay, date of discharge, cause of discharge or death, detailed notes before and after an operation and before and after anaesthesia, name of the surgeon and anaesthetist.

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