Purpose – Clinical data capture and transfer are becoming more important as hospital practices change. Medical record pro‐formas are widely used but their efficacy in acute settings is unclear. This paper aims to assess whether pro‐forma and aide‐memoire recording aids influence data collection in acute medical and surgical admission records completed by junior doctors. Design/methodology/approach – During October 2007 to January 2008, 150 medical and 150 surgical admission records were randomly selected. Each was analysed using Royal College of Physicians guidelines. Surgical record deficiencies were highlighted in an aide‐memoire printed on all A4 admission sheets. One year later, the exercise was repeated for 199 admissions. Findings – Initial assessment demonstrated similar data capture rates, 77.4 per cent and 75.9 per cent for medicine and surgery respectively ( Z =‐0.74, p =0.458). Following the aide‐memoire 's introduction, surgical information recording improved relatively, 70.5 per cent and 73.9 per cent respectively ( Z =2.01, p =0.045). One from 11 aide‐memoire categories was associated with improvement following clinical training. There was an overall fall in admission record quality during 2008‐9 vs 2007‐8. Research limitations/implications – The study compared performance among two groups of doctors working simultaneously in separate wards, representing four months' activity. Practical implications – Hospital managers and clinicians should be mindful that innovations successful in elective clinical practice might not be transferable to an acute setting. Originality/value – This audit shows that in an acute setting, over one‐quarter of clinical admission data were not captured and devices aimed at improving data capture had no demonstrable effect. The authors suggest that in current hospital practice, focussed clinical training is more likely to improve patient admission records than employing recording aids.
International Journal of Health Care Quality Assurance – Emerald Publishing
Published: Jan 4, 2013
Keywords: Patient records; Acute admissions; Service quality; Wales; Hospitals; Medical care; Records management; Medical treatment
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