ALLERGIES DOCUMENTATION IN HMIS HISTORY OF PATIENTS ADMITTED IN GASTROENTEROLOGY AND PULMONOLOGY WARD AT LADY READING HOSPITAL, MEDICAL TEACHING INSTITUTE – PESHAWAR

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BACKGROUND: This clinical audit aimed to assess the accuracy of allergy documentation within the Hospital Management Information System (HMIS) of the Gastroenterology and Pulmonology Wards at Lady Reading Hospital, MTI Peshawar. Proper documentation of allergies, including food, drugs, and other types, is crucial for patient safety to prevent adverse reactions. METHODS: The clinical audit was conducted using the "HOPE" Hospital Management Information System (HMIS), donated by the Shaukat Khanum Memorial Trust. It involved a retrospective review of medical records for 20 patients from each ward across two audit cycles. In the first cycle, 10 patients were randomly selected from each ward, making a total of 20 patients. After identifying gaps in allergy documentation, interventions were implemented. A second cycle was then conducted to reassess documentation, selecting another set of 10 patients from each ward. Data collection involved checking if allergies were documented, and the results were recorded in an Excel sheet, marked as 'Yes' or 'No' for allergies. Data analysis was done using Microsoft Excel 2023 and the graphical representations were created in Microsoft Office Word 2023 and Microsoft Excel 2023 (Microsoft® Corp., Redmond, WA). The audit aimed for a 100% documentation standard as per the HMIS reading manual. RESULTS: In the first cycle, 70% (n=7) of patients in the Gastroenterology Ward and 60% (n=6) in the Pulmonology Ward had no documented allergies. After implementing the recommended interventions, the second cycle showed a remarkable improvement, with a 100% documentation rate achieved in both wards. CONCLUSIONS: After implementing the recommendations, allergy documentation in the HMIS of Lady Reading Hospital MTI Peshawar significantly improved, which helped in preventing allergic reactions in patients admitted to the Gastroenterology and Pulmonology Wards.

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