RT Journal Article
SR Electronic
T1 How complete are our clerkings? A project aimed at improving the quality of medical records by using a standardised proforma.
JF BMJ Quality Improvement Reports
JO BMJ Qual Improv Report
FD British Medical Journal Publishing Group
SP u203012.w1388
DO 10.1136/bmjquality.u203012.w1388
VO 2
IS 2
A1 Jij Chow
A1 Camille Yvon
A1 Tim Stanger
YR 2014
UL http://bmjopenquality.bmj.com/content/2/2/u203012.w1388.abstract
AB Clerking a patient is the first and most important contact that any medical team has with the patient. It provides information that may not be available later in the admission if recorded improperly, such as referral letters, collateral history, dosette boxes or prescription sheets. The quality of data recorded from this encounter was examined at a busy district general hospital surgical department. Initial measurement demonstrated that less than half of certain key parameters like dosages of medication were being recorded by clerking doctors. A clerking proforma was therefore designed to combat this problem. Over three audit cycles (n = 170, 150, 174) the proforma showed statistically significant improvements in the proportion of data that was captured at initial contact with the patient. We conclude that the introduction of proformas for clerking significantly improves the collection of data that impacts patient care during their hospital stay.