Background Accurate admission documentation is essential for safe and effective clinical care. It facilitates diagnosis, treatment planning, team communication, legal protection, and quality improvement. However, audits globally, including in low-resource settings, report major gaps in documentation quality, which may jeopardize patient outcomes and healthcare operations. Objective The objective of this study is to assess the quality and completeness of admission documentation in the Pulmonology Unit of MTI Mardan Medical Complex (MMC), Pakistan, against national and international standards. Methods This retrospective clinical audit reviewed 150 systematically selected patient admission records from January 1 to March 31, 2025. A structured audit tool, based on NHS and institutional guidelines, evaluated key documentation domains: demographics, history, examination, investigations, diagnosis, and initial management. Data were analyzed using descriptive statistics in Microsoft Excel. Results Only 1% (n = 1) of admission notes met all documentation standards. While demographics like name and age were documented in over 95% (n ≈ 143-150) of records, critical components were frequently missing. Presenting complaints were noted in 93% (n = 140), but detailed symptom analysis appeared in only 35% (n = 52), and red flag symptoms in 35% (n = 52). Medication history, allergy status, and vaccination history were missing in nearly all charts (98-100% missing, n = 147-150). Physical examination findings and vital signs were poorly recorded (3-61% = n = 5 to 92). Investigations and differential diagnoses were documented in less than 11% (n < 17) of cases. While 75% (n = 113) of records included an initial management plan, communication with patients or families was not documented in any case (0%, n = 0). Conclusion Significant documentation deficiencies were identified across multiple domains. Implementing a standardized admission template and conducting clinician training may improve compliance and patient care. Regular re-audits are recommended to assess ongoing progress.
Ali et al. (Sun,) studied this question.