Introduction
Problem
Audits on record-keeping practices at our multidisciplinary hospital revealed that ward-round notes (handwritten clinical notes by the doctor during ward round) were unstructured and carried limited as well as dissimilar information chosen differently by different doctors. While there was satisfactory compliance with regularity, legibility, timing, drug prescriptions, investigation records and vital monitoring, there was marked inconsistency in the reporting of clinical information between doctors. This risked omission of vital facts such as developments during hospital stay, impression of progress, revision in clinical diagnosis, justification for change in medicines or advice for a new test. The paediatric team realized that this inconsistent and incomplete documentation lead to lack of clarity in communication between paediatricians which in turn could compromise patient safety and medico-legal integrity. To address these concerns the department decided to focus on improving their documentation (online supplemental figure 1, fishbone diagram).
Available knowledge
Well-written case notes provide accountability, corroborate the delivery of appropriate services, support clinical decisions,1 2 promote effective communication and prevent patient harm.3 Inadequate communication between different health professionals is associated with discontinuity of care, which can lead to errors and compromise patient safety.4 In present times, clinical notes also serve as a valuable document to audit the quality of healthcare services offered,5 determine issuance of insurance claims and, importantly, serve as a documentary evidence for medicolegal purpose.6
Despite its importance, clinical record keeping is often given a low priority, and it is common to find missing information and inconsistency between the entries.5 Often, there is great variability in the format of clinical notes among different healthcare professionals and hospitals in different countries.5 These may be influenced by the doctor’s/healthcare professional’s years of experience, previous incidents (i.e. lessons that have been learnt) and relevant circumstances of the case (acute deterioration of the patient, etc).5 In densely populated nations such as ours, an additional role is played by limited consult times from enormous caseloads, resulting in priority towards clinical interaction over documentation.7
The onus for improving records lies with individual health professionals. Structuring the clinical records especially at the time of admission is known to improve the quality of information recorded.8–10 This reduces clinical errors and improves patient outcomes.8 In the same context, ward-round proforma or templates have been employed to standardise recording of patient progress. This has demonstrated an improvement in documentation practices,11–13 patient safety,4 12 14 15 efficiency in ward rounds16 as well as completeness of records.17 These proformas have been typically designed to capture comprehensive information pertaining to a particular specialty (eg, surgery or orthopaedics4 12 13 15–17) or a disease (eg, deep venous thromboembolism).14
Another method commonly applied to improve documentation practices has been audit exercises to sensitise doctors regarding their performance. This includes educating them via trainings or reminder communications to perform against a benchmark. These audits engage either a concerned specialty centric template (eg, Shark, Crabel, Star, to name a few)18–20 or adhere to norms defined by quality accreditation programmes.21 22
Both proforma as well as audit templates have focused on comprehensive aspects of record keeping such as investigations, drug prescription, information to patients, date and time of records, and regularity besides characteristics of the clinical information. There appears to be a paucity of literature demonstrating methods focused only on the nature of the clinical information relayed in the note.