RT Journal Article
SR Electronic
T1 Evaluating the Quality of Medical Documentation at a University Teaching Hospital
JF BMJ Quality Improvement Reports
JO BMJ Qual Improv Report
FD British Medical Journal Publishing Group
SP u208052.w3253
DO 10.1136/bmjquality.u208052.w3253
VO 4
IS 1
A1 Ridyard, Edward
A1 Street, Elliot
YR 2015
UL http://bmjopenquality.bmj.com/content/4/1/u208052.w3253.abstract
AB A recent joint publication by the Royal College of Physicians and Royal College of Nursing raised concern regarding the variability in the organisation and quality of documentation during ward rounds [1]. The aim of the study was to evaluate the standard of medical documentation at a University Teaching Hospital. Retrospective manual analysis of patient’s paper and electronic paper records (EPR) from the different specialties. Inclusion criteria included in-patient stay of more than two days and admission after 1st July 2013. A VTE assessment was available in 100% of patients. The plan and postoperative instructions were available in 100% of patients. Notes were documented contemporaneously in 75% of cases which increased to 80% in the second following by 89.11% in the third cycle. If a consultant was present on the ward round this was documented in 80% of cases in the first cycle. This subsequently increased to 90% in the second cycle and 100% in the third cycle. Overall the quality of medical documentation was of a reasonable standard but could be improved even further if we continue to document contemporaneously and name every person present at each patient encounter.