Improving admission clerking standards and physical health assessments in febrile patients: A prospective clinical audit at a tertiary care hospital.

INTRODUCTION: Clinical audit is an effective tool to improve patient care, which in turn has an impact on clinical outcome.Patients who present with fever usually are generally admitted based on competency-based criteria, where admission is determined on the severity of the illness assessed through clinical and laboratory findings. Bacterial infections were linked to high sepsis-related mortality. This highlights the importance of comprehensive and standardized admission clerking and physical assessment for patients presenting with fever. This audit aimed to evaluate the documentation of history, physical examination, and investigations in febrile patients by postgraduate trainees at a tertiary care hospital in South India.

METHODS: A prospective audit of 50 case records of patients admitted with fever was conducted over a four-week period in the medical wards. A predefined pro forma was used to review key domains, including documentation of admission details, clinical history, physical examination (vital signs and systemic examination), and relevant investigations. Findings were measured against departmental standards and analyzed to identify areas for improvement.

RESULTS: Documentation completeness by the post graduate trainee's completeness varied across domains. Admission details were documented in 86% of cases, and comprehensive history was recorded in 72%. While vital signs were documented well (>90%), systemic examination showed significant variability (CVS: 80% vs CNS: 66%). Documentation of specific investigations was inconsistent: dengue serology (62%), WIDAL test or blood culture (54%), and Scrub typhus serology (38%).

CONCLUSION: The clinical audit revealed notable variability in admission documentation by postgraduate trainees, particularly in the systemic examination and investigation domains. The findings highlight the need for targeted educational interventions and reinforcement of documentation protocols to enhance patient assessment and care, particularly in febrile patients, where inadequate management can lead to high case fatality.