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Background: Effective documentation is essential for ensuring high-quality clinical practice. Medical notes serve as a crucial form of communication among all those who are involved in a patient’s care. Therefore, it is important to have a quality assurance mechanism in place to ensure that medical records comply with established standards.Objective: To evaluate the quality of medical notes writing in different departments of Mangail Teaching Hospital, and to implement some possible solutions to improve the quality of existing medical records and overcome the deficiencies.Methodology: A retrospective, prospective observational audit carried out in Managil Teaching Hospital, we included 108 files in both audit cycles, 54 in each. Sampling was done through a systematic simple random sampling method over a period of one week for every cycle. Data were collected and each file was compared to the Royal College of Physician standards, the collected data were entered into an Excel sheet, cleaned then analyzed using Statistical Package for Social Sciences (SPSS) version 25 using frequency tables test.Results: A total of 108 samples were included. In the 1st cycle only 16.1% of doctors wrote the patient’s occupation, and 14.3% wrote the contact number, regarding the history section only 41.1% documented the patient’s history of presenting complaint. In the 2nd cycle, 74% documented the occupation, 76% wrote the contact number. One hundred percent have documented the patient’s history of presenting complaint. The overall impression was excellent in 0% in the 1st cycle and 55.6% in the 2nd cycle.Conclusion: Documentation practice in our teaching hospital did not meet the standards and the evaluating parameters used in the assessment showed high percentage of poor and unsatisfactory practice during the 1st cycle, however after a series of medical practitioner’s orientation a significant improvement was observed regarding inpatient medical records filling.

Background: Owing to its importance in detecting airway, lung, heart, blood vessel, and bone problems, chest radiography is the most prevalent diagnostic test. To ensure accuracy, the images must be evaluated technically. Once images are sufficiently good, radiologists can interpret radiographs more confidently and clinicians can diagnose them accurately. We aimed to evaluate and improve the technical posteroanterior (PA) chest X-ray (CXR) procedure.Methodology: A Retrospective, Prospective observational audit conducted at Managil Teaching Hospital and adjacent private radiology clinics in the 1st cycle 21 CXR was gathered and compared to the American College of Radiology (ACR) standards, and an initial Microsoft Excel® analysis identified substantial radiographic quality issues. Based on these findings, radiology staff training was ensued, and clinicians used a predesigned questionnaire to check the completeness of the requested image. Moreover, the department publicly posted posters defining quality PA CXR requirements based on ACR guidelines. These interventions were followed by data collection and analysis in the 2nd cycle with 41 CXR. The total sample size of the study was 62 patients.Results: A total of 41 CXR images were included in the study, 21 in the 1st cycle and 20 in the 2nd cycle, in the first cycle the collected data were compared with the ACR standards, A significant improvement was observed in most areas after the 2nd cycle, for instance the first criteria was the CXR should be Performed at full inspiration it was only in 67.20% during the 1st cycle and 90% in the 2nd cycle.Conclusion: The medical audit shows that the quality improvement efforts of the Managil Teaching Hospital have improved the PA CXR technicalities. Following the standards of the American College of Radiology (ACR) standards, the audit showed improvements in most anatomical imaging criteria post-intervention.