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Evaluating the Quality of Medical Documentation at a University Teaching Hospital
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 Teac...
Autores principales: | , |
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Formato: | Online Artículo Texto |
Lenguaje: | English |
Publicado: |
British Publishing Group
2015
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Materias: | |
Acceso en línea: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4645821/ https://www.ncbi.nlm.nih.gov/pubmed/26734328 http://dx.doi.org/10.1136/bmjquality.u208052.w3253 |
Sumario: | 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. |
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