An Evaluation of Medical Record Keeping Status to Assess Health Care Facilities for Hospitalized Patients In A Tertiary Care Hospital

Background: A patient’s medical record should provide accurate information on who the patient is and provided health care; what, when, why how services were provided; outcome of care treatment. Objectives: The study was conducted with objective revealing condition audit inpatient department in Rangpur college hospital short duration time. Materials Methods: cross-sectional descriptive done Medical College & Hospital. This carried out 160 documents, interview providers, statistics personal observation physical facilities indoor at time to find what extend exist service. Results: In Hospital, generation location form all wards inpatient, administrative office type forms mixed pattern. There no electronic system medicine department. They consisted forms, sheet register khata. records not filled most cases. hundred sixty checked where components up completely (above 30% up). recording satisfactory maintained regularly Conclusion: standard documentation by providers found be acceptable, improvements required a number specific items. KYAMC Journal Vol. 13, No. 02, July 2022: 81-85