Asian Journal of Medical Principles and Clinical Practice

Background: Clinical documentation is a cornerstone of quality healthcare and patient safety. The accuracy and completeness of patient records are essential for effective clinical decision-making and continuity of care. The Bed Head Ticket (BHT) serves as the principal medical record for inpatient care in Sri Lanka. This study aimed to assess compliance with established clinical documentation standards at Teaching Hospital Kalutara, Sri Lanka.

Methods: A cross-sectional audit was conducted using 100 BHTs of patients admitted to Teaching Hospital Kalutara, Sri Lanka. The audit assessed documentation practices across five key areas: the front page (admission sheet), continuation sheets, individual entries, comprehensive documentation aspects, and changes to documented records. Compliance with predefined standards outlined by the Ministry of Health, Sri Lanka (HQSH/01/2022), was evaluated.

Results: The findings indicated significant gaps in several areas of clinical documentation. For the front page (admission sheet), information completeness was low, with allergy status and blood group documentation absent from all records. Continuation sheets showed high integrity (98%) but suboptimal organisation and staff entry documentation, with compliance rates of 56% and 58%, respectively. For individual entries, chronological order was strictly followed (100%), but identification of the entry maker was poorly documented, with 27% including a name and none including a signature. Comprehensive documentation practices varied; although history and examination findings were well documented (99% and 98%, respectively), differential diagnoses were recorded in only 18% of records. Changes to documented records were identified in 5% of BHTs; however, none followed the standard correction procedure.

Conclusion: The audit revealed substantial deficiencies in clinical documentation practices at Teaching Hospital Kalutara, Sri Lanka, particularly in the admission sheet, identification of entry makers, and documentation of differential diagnoses. These findings highlight the need for targeted interventions to improve documentation practices, including staff training on relevant standards and guidelines. Adherence to appropriate documentation practices is important for strengthening patient care, safety, and medico-legal protection.