Vol. 11, Issue 8, Part E (2025)

Abstract
Medical records are critical for patient care, legal compliance, and quality assurance in healthcare. Despite existing guidelines like NABH and JCI, poor documentation remains a global challenge. This study aimed to assess the completeness and accuracy of inpatient medical records and identify documentation gaps. A retrospective and prospective observational audit was conducted in a NABH-accredited super-speciality hospital in Guwahati, Assam, during July 2025. A total of 100 inpatient files (50 active, 50 discharged) from all wards were evaluated using a NABH-based checklist covering patient history, doctor’s orders, medication charts, and discharge summaries. Results showed 100% completeness in doctor’s orders, pre-admission diagnosis, progress notes, and discharge summaries, with the highest sample share from the Cabin ward (51%). Minor lapses were observed in files of patients admitted after 5 PM, likely due to shift changes. Overall, documentation adhered to NABH standards with excellent compliance. Continuous training, regular audits, and technology adoption are recommended to sustain accuracy and improve documentation quality.