STAMPING OUT BAD DOCUMENTATION: A COMPLETE AUDIT CYCLE
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STAMPING OUT BAD DOCUMENTATION: A COMPLETE AUDIT CYCLE Gemma Gough & Katie Mageean ST1 Paediatrics, Royal United Hospital, Bath [email protected]; [email protected] BACKGROUND: Accurate documentation in patient notes is a legal requirement and is vital for effective communication, and ultimately good patient care. Its importance is highlighted as an essential aspect of Good Medical Practice by the General Medical Council 1 . AIM: To audit current documentation standards in the paediatric department (Children’s Ward and NICU) of the Royal United Hospital, Bath, to make appropriate recommendations and assess their effectiveness through re-audit. METHOD: The Audit Cycle 1& 5. Criteria and standards set/revised: 9 criteria based on guidance from professional bodies 1-3 and local trust policy. Standards set at 100% for each criteria. 2&6. Data collection: All inpatient notes audited (5 entries from each set of notes); each entry assessed against set criteria. 3&7. Results and Feedback: Audit data presented to paediatric department, recommendations agreed upon. 4. Recommendations implemented: Personalised stamps introduced with Name & GMC No. CRITERIA CYCLE 1 (n=188) CYCLE 2 (n=161) Patient ID x 3(Name, DOB, NHS/Hospital No.) 21 90 Entry Dated 83 93 Entry Timed 74 83 Entry Titled 52 58 Name Signed 89 96 Name Printed 65 83 GMC No. (Non-doctors excluded) 4 27 Bleep/contact No. 57 45 Designation 58 67 Table 1. Results for fulfilment of each criteria, expressed as a percentage of all entries Compliance (%) 90-100 75-89 <75 RESULTS: DISCUSSION: • Cycle 1 : No entry fulfilled all 9 criteria • Weakest areas were 3 points of patient ID (on the front and back of the page) and GMC No. • Audit presented in departmental meeting to raise awareness, and recommendations made: • Personalised name/GMC No. stamps (bought voluntarily by a small number of junior doctors) • Patient ID labels in all patient notes (not implemented prior to cycle 2, but under discussion) • 3 points of patient ID required on front of page only, in line with local trust guidance • Cycle 2 : 7% of entries fulfilled all 9 criteria with improvement in all areas except bleep/contact no. • Greatest improvements seen in patient ID and GMC No. • Further recommendations made to provide all clinicians with personalised stamps, continue discussion regarding provision of patient ID labels, and maintain awareness of documentation standards through regular re-audits and discussion. CONCLUSION: Documentation in the paediatric department was below ideal standards, which could have a significant impact on patient care. The introduction of personalised stamps and raising awareness of the importance of documentation has improved documentation standards in the department. The trust is now providing stamps for all new starters. This will contribute to continued improvement in documentation and patient safety. References: 1 Good Medical Practice guidelines (2013) www.gmc-uk.org/guidance/good_medical_practice.asp 2 MPS Factsheets- Medical Records www.medicalprotection.org/uk/england- factsheets/medical-records 3 Generic medical record keeping standards- Royal College of Physicians www.rcplondon.ac.uk/resources/generic-medical-record-keeping-standards
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STAMPING OUT BAD DOCUMENTATION: A COMPLETE AUDIT CYCLE Gemma Gough & Katie Mageean ST1 Paediatrics, Royal United Hospital, Bath [email protected]; [email protected]. AIM: - PowerPoint PPT Presentation
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STAMPING OUT BAD DOCUMENTATION: A COMPLETE AUDIT CYCLE Gemma Gough & Katie Mageean ST1 Paediatrics, Royal United Hospital, Bath [email protected]; [email protected]
BACKGROUND:Accurate documentation in patient notes is a legal requirement and is vital for effective communication, and ultimately good patient care. Its importance is highlighted as an essential aspect of Good Medical Practice by the General Medical Council 1.
AIM:To audit current documentation standards in the paediatric department (Children’s Ward and NICU) of the Royal United Hospital, Bath, to make appropriate recommendations and assess their effectiveness through re-audit.
METHOD:The Audit Cycle
1& 5. Criteria and standards set/revised: 9 criteria based on guidance from professional
bodies1-3 and local trust policy. Standards set at 100% for each criteria.
2&6. Data collection:All inpatient notes audited (5 entries from
each set of notes); each entry assessed against set criteria.
3&7. Results and Feedback: Audit data presented to paediatric
department, recommendations agreed upon.
4. Recommendations implemented: Personalised stamps introduced with
Name & GMC No.
CRITERIA CYCLE 1 (n=188) CYCLE 2 (n=161)
Patient ID x 3(Name, DOB, NHS/Hospital No.) 21 90
Entry Dated 83 93
Entry Timed 74 83
Entry Titled 52 58
Name Signed 89 96
Name Printed 65 83
GMC No. (Non-doctors excluded) 4 27
Bleep/contact No. 57 45
Designation 58 67
Table 1. Results for fulfilment of each criteria, expressed as a percentage of all entriesCompliance (%) 90-100 75-89 <75
RESULTS:
DISCUSSION:• Cycle 1: No entry fulfilled all 9 criteria• Weakest areas were 3 points of patient ID (on the front and back of the page) and GMC No.• Audit presented in departmental meeting to raise awareness, and recommendations made:
• Personalised name/GMC No. stamps (bought voluntarily by a small number of junior doctors)
• Patient ID labels in all patient notes (not implemented prior to cycle 2, but under discussion)
• 3 points of patient ID required on front of page only, in line with local trust guidance• Cycle 2: 7% of entries fulfilled all 9 criteria with improvement in all areas except bleep/contact
no.• Greatest improvements seen in patient ID and GMC No. • Further recommendations made to provide all clinicians with personalised stamps, continue
discussion regarding provision of patient ID labels, and maintain awareness of documentation standards through regular re-audits and discussion.
CONCLUSION: Documentation in the paediatric department was below ideal standards, which could have a significant impact on patient care. The introduction of personalised stamps and raising awareness of the importance of documentation has improved documentation standards in the department. The trust is now providing stamps for all new starters.
This will contribute to continued improvement in documentation and patient safety.
References: 1Good Medical Practice guidelines (2013) www.gmc-uk.org/guidance/good_medical_practice.asp 2MPS Factsheets- Medical Records www.medicalprotection.org/uk/england-factsheets/medical-records 3Generic medical record keeping standards- Royal College of Physicians www.rcplondon.ac.uk/resources/generic-medical-record-keeping-standards
