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Research Scholar, Faculty of Business Administration, Department of Entrepreneurship Studies, Madurai Kamaraj University; Principal, Vadamalayan Institute of Medical and Allied Health Sciences, Madurai, Tamil Nadu India
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Professor & Head (Retired), Department of Entrepreneurship Studies, Madurai Kamaraj University , Madurai, Tamil Nadu , India
Assistant Professor, Department of Entrepreneurship Studies, Madurai Kamaraj University , Madurai, Tamil Nadu , India
In multi-specialty hospitals, maintaining comprehensive and accurate medical records is a mechanical necessity for high-quality care, regulatory compliance, and medicolegal protection. While physicians are the primary authors of these clinical records, a focus on care execution over documentation often leads to critical gaps in recording patient progress and treatment notes. This study investigates physician documentation completeness in three vulnerable areas: initial patient assessment, surgical consent, and discharge planning within a medium-resource multispecialty teaching hospital. Employing a quantitative descriptive design and a concurrent survey method, the study utilized convenience sampling to audit inpatient records. A total of N = 364 records were analyzed for initial patient assessment, N = 142 for surgical consent, and N = 248 for discharge documentation. Data were processed using descriptive statistics to identify compliance gaps. Significant documentation non-compliance was observed across all surveyed domains. The completion rate for initial patient assessments was 57.14%, leaving a 42.86% gap in essential admission data. Within surgical consent documentation, though administrative details were high (98.6%), critical clinical elements were severely lacking: 60.6% of records omitted specific procedure details, 54.2% lacked physician signatures, and 66.6% lacked surgeon identifiers. Furthermore, discharge documentation showed that 72.6% of records lacked advice given during rounds, and 49.2% failed to record the consultant's final discharge instructions. The findings confirm that incomplete documentation remains a major threat to patient safety and institutional accountability. The high rates of missing surgical procedure details and physician identifiers compromise traceability and legal safeguards. Institutional reforms, including the implementation of standardized templates and the integration of medical documentation into professional curricula, are recommended to bridge these systemic gaps.
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