Hospital case notes and medical audit.

Hospital case notes and medical audit: evaluation of non-response.

Notes: a suitable case for audit.

The increasing emphasis on management responsibilities and audit led us to investigate the state of surgical notes in our hospital. Twelve criteria were evaluated regarding information that should be contained in the notes and the absence of this important information was documented. Deficiencies were revealed in all criteria selected. Until hospital patients files are well kept and maintained,...

Incompleteness and retrieval of case notes in a case note audit of colorectal cancer.

Hospital case notes are a crucial source of data but are subject to two major biases: incompleteness of data and non-retrieval. To assess these biases in relation to colorectal cancer a study was performed of all cases of colorectal cancer listed in the Thames cancer registry in patients resident in one of four districts in South Thames regions with a diagnosis in 1988. Five medical record site...

Notes of Cases Treated in the Medical College Hospital

Gouka, a Hindoo girl, aged 10 years, a resident of Burra Bazaar, was admitted on the 21st August, 1865, at p. m. She had a fall from the roof of a two-storied house at 6 p. m. that day, and remained insensible for an hour after the accident. When she was brought to the hospital she had rallied and was complaining of pain in both the forearms. On examination, Colles' fracture was detected on bot...

Medical records, medical audit, and community hospitals.

A survey of community hospitals suggests a need for improving medical records and communications and introducing review procedures. A new and extended system based on an A4 size unit record is described. The benefits of a medical audit procedure in which all general practitioners and senior nurses participate are discussed.