clinical audits and the state of record keeping in india

There is no legislative framework in In-dia at the moment, which would enable collating data from hospitals on standard indicators of quality of patient care. It is only such data on patient care processes and outcomes, which would enable any meaningful audit of medical services with a view to making these services patient oriented. Hospital services should be such as to facilitate better patient outcomes and should be consistent with current professional knowledge. But without any data on quality of care indicators, there is no way to identify areas which need improvement and which could indeed enable patients to be better served. It is structured data on large numbers of patients from any specific institution over a reasonable period of time and also across institutions and adjusted for risk, which would enable care providers to identify and address la-cunae. But without any law which says this should be done, it is only data which managements consider important which is captured. Many individual doctors also record data regarding their own patients but unless they have access to structured data about a larger patient set, it would be difficult to see why some patients in similar circumstances get better and others don't. We routinely hear discussions about bed occupancy rates and the cost of medical services because data is readily available about these parameters. But patient oriented data whether it be about mortality and post-operative complications or about medications or about infection rates is rarely available; so it is rarely discussed. It is as a result of lack of legal requirements that clinical audits to improve the quality of care for in-patients in Indian hospitals, come up repeatedly against the poor quality of medical records. The majority of hospitals do not even record patient history in detail and information about treatment provided is sometimes as scanty. Recently when asked to provide Operation Theatre notes for some complicated case in a health insurance scheme, one doctor wanted to know why it was necessary to record any notes; was it not sufficient to record the name of the surgical procedure conducted. Such na-ivete is a telling comment on the state of medical records in India. Surgery volumes for different procedures, mortality rates both procedure wise and disease wise, post-operative complications and infection rates are good indicators of the quality of in-patient care, provided that such data is recorded in structured formats. Currently such data …