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Evaluating the Quality of Medical Documentation at a University Teaching Hospital
- Source :
- BMJ Quality Improvement Reports
- Publication Year :
- 2015
- Publisher :
- BMJ, 2015.
-
Abstract
- 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.
- Subjects :
- medicine.medical_specialty
Ward round
BMJ Quality Improvement Programme
Person present
business.industry
media_common.quotation_subject
MEDLINE
Alternative medicine
General Medicine
medicine.disease
Bioinformatics
Medical documents
Documentation
Medicine
Quality (business)
University teaching
Medical emergency
business
media_common
Subjects
Details
- ISSN :
- 20501315
- Volume :
- 4
- Database :
- OpenAIRE
- Journal :
- BMJ Quality Improvement Reports
- Accession number :
- edsair.doi.dedup.....fd396193dafdce2110fc1beaf86bf7f9