An audit to evaluate record keeping in orthopaedic and trauma wards in James Cook University Hospital (JCUH)

ABSTRACT NUMBER: (NESTAC_11)

 

AUTHORS
Shivam Rana

AFFILIATIONS
Newcastle University
(under supervision of Professor Amar Rangan, Orthopaedics Surgeon, James Cook University Hospital)

CORRESPONDING AUTHOR CONTACT EMAIL
ku.ca.eltsacwen@4anar.s

MAIN ABSTRACT TEXT

Background
Good record keeping is of paramount importance for patient safety and for medico-legal reasons. The diligence with which patient information is recorded may reflect the quality of care provided to our patients.

Furthermore, poor record keeping can hinder communication between healthcare professionals and therefore impacts continuity of care.

Aim
This audit compared current standards of patient records on orthopaedic and trauma wards within JCUH against record keeping standards suggested by the Royal College of Surgeons (RCS) as per ‘Good Surgical Practice’.

Methods
A checklist was created from RCS guidelines with 8 domains including: proper corrections, use of blue/black ink, all entries legible, all entries signed, all entries timed, all entries dated, patient name and number on all pages, and 1st entry standards which further included name in capitals, job title and registration number.

Results
Analysing 40 patient records found that only 4 domains met the set standards of 100% completion which included: proper corrections, use of blue/black ink, all entries signed, and all entries dated. It also showed that all entries except 1st entry standards scored 90% or over completion rate. Additionally, 1st entries were completed poorly (70%) with registration number written only 80% of the time.

Conclusions
Half of the domains assessed could be improved, with input of registration numbers in 1st entries having the biggest scope for improvement. The majority of 1st entries were made by junior doctors, therefore the need for good record keeping should be highlighted during junior doctor inductions and teaching sessions.