Surgical audit of Neurosurgery Patients Admitted to a Tertiary Care Hospital in Terms of Record and Documentation

Objectives

The aim of performing this audit is to observe and analyze record keeping and documentation of all the patients admitted to neurosurgery department in a tertiary care hospital in Peshawar Khyber Pakhtunkhwa Pakistan.

Materials and Methods

The audit cycle was conducted in a retrospective manner and data pertaining to all the admitted patients in neurosurgical department was collected from January 2018 to December 2022. A total of 1305 patients were enrolled in this audit admitted through OPD and emergency. The variables that were included in the audit cycle are the following: Name, age, gender, date of admission, medical record number (MR number), disease and the treatment given. Data was collected in a pre-designed proforma, added to Microsoft excel sheet and analyzed through SPSS software version 23.0. The data was described in the form of description, charts and tables.

Results

Out of 1305 patients enrolled in the study, we noticed that 1244 patient's (95%) names, 1079 (82.7%) hospital registration numbers, 1208 (99.5%) dates of admissions/discharges, 1252 (96%) genders and 99% of the diseases and procedures done were properly recorded. No record was available related to the address, contact numbers and occupations of the patients.

Conclusion

Despite having a few deficiencies, it is safe to conclude that most of the data pertaining to neurosurgery patients was properly recorded and kept in follow-up as shown by the results. We call attention to conducting audits on a regular basis that will further cover up the loopholes in data alimentation and improve our catalogue even further.