Audits
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
R. M. Wijesiriwardane,
Lady Ridgeway Hospital for Children, Colombo, LK
About R. M.
Registrar in Psychiatry
B. D. J. V. Peiris,
Lady Ridgeway Hospital for Children, Colombo, LK
About B. D. J. V.
Registrar in Psychiatry
D. M. A. Dahanayake
University of Colombo, LK
About D. M. A.
Senior Lecturer in Psychiatry and Consultant Child & Adolescent Psychiatrist, Faculty of Medicine
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
Published on
31 Dec 2022.
Peer Reviewed
Downloads
