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Clinical Audit on Record Keeping Standards at a Specialized Out-patient Child Psychiatry Service in Sri Lanka

Authors:

P. K. D. H. J. L. De Silva Rajaratne ,

Lady Ridgeway Hospital for Children, Colombo, LK
About P. K. D. H. J. L.
Senior Registrar in Child and Adolescent Psychiatry
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R. M. Wijesiriwardane,

Lady Ridgeway Hospital for Children, Colombo, LK
About R. M.
Registrar in Psychiatry
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B. D. J. V. Peiris,

Lady Ridgeway Hospital for Children, Colombo, LK
About B. D. J. V.
Registrar in Psychiatry
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D. M. A. Dahanayake

University of Colombo, LK
About D. M. A.
Senior Lecturer in Psychiatry and Consultant Child & Adolescent Psychiatrist, Faculty of Medicine
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Abstract

Background: Accurate and up-to-date patient records are essential to ensure high standards of clinical care and achieve professional standards from a medico-legal perspective.

 

Objectives: This clinical audit aimed to investigate record keeping practices including documentation of the evaluation, execution of management plan and confidentiality of record organization.

 

Methods: Paper-based clinical records of 250 outpatients were reviewed randomly using an evaluation form.

 

Results: Although the confidentiality of record organization and execution of the management plan were satisfactory, serious concerns were identified regarding the documentation of evaluation.

 

Conclusions: The audit showed current record-keeping deficiencies, highlighting the need for record-keeping procedures and policies. 

How to Cite: De Silva Rajaratne, P.K.D.H.J.L., Wijesiriwardane, R.M., Peiris, B.D.J.V. and Dahanayake, D.M.A., 2022. Clinical Audit on Record Keeping Standards at a Specialized Out-patient Child Psychiatry Service in Sri Lanka. Sri Lanka Journal of Medicine, 31(2), pp.97–101. DOI: http://doi.org/10.4038/sljm.v31i2.338
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Published on 31 Dec 2022.
Peer Reviewed

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