Evaluation of audit of medical inpatient records in a district general hospital

Assessment of junior doctors' admission notes: do they follow what they learn?

OBJECTIVES

To assess the completeness of history-taking and physical-examination notes of junior doctors at King Abdulaziz University Hospital per the approach they learned in medical school.

METHODS

In this retrospective study, we reviewed 860 admission notes written by 269 junior doctors (interns and residents) in an academic tertiary-care medical centre in Jeddah, Saudi Arabia, over a two-month period. Notes were evaluated for completeness using a checklist developed with reference to relevant medical textbooks. The checklist included 32 items related to history-taking and physical examination. Based on the review of the notes, checklist items were evaluated as complete, incomplete, not present, or not applicable according to set criteria. Data were analysed and summarised for information on the frequency and relative frequency of these types.

RESULTS

The history items varied in completeness. At the high end, asking about chief complaint and duration, associated symptoms, aggravating and relieving factors, and conducting systemic review were marked 'complete' in 74.2%, 81.7%, 80.4%, and 79.7% of notes, respectively. At the low end, asking about previous episodes, allergies, medications, and family history were complete in 5.3%, 1.9%, 4.8%, and 2.9% of notes, respectively. All physical examination items were poorly documented, especially breast examination, which was 'not present' in 95.8% of the notes.

CONCLUSIONS

Junior doctors' history and physical-examination notes are often incomplete and do not follow the approach taught in medical school. The reasons for this must be studied via focus-group discussions with junior doctors.

Medical record-keeping and patient perception of hospital care quality

Purpose

– Medical record represents the main information support used by healthcare providers. The purpose of this paper is to examine whether patient perception of hospital care quality related to compliance with medical-record keeping.

Design/methodology/approach

– The authors merged the original data collected as part of a nationwide audit of medical records with overall and subscale perception scores (range 0-100, with higher scores denoting better rating) computed for 191 respondents to a cross-sectional survey of patients discharged from a university hospital.

Findings

– The median overall patient perception score was 77 (25th-75th percentiles, 68-87) and differed according to the presence of discharge summary completed within eight days of discharge (81 v. 75, p=0.03 after adjusting for baseline patient and hospital stay characteristics). No independent associations were found between patient perception scores and the documentation of pain assessment and nutritional disorder screening. Yet, medical record-keeping quality was independently associated with higher patient perception scores for the nurses’ interpersonal and technical skills component.

Research limitations/implications

– First, this was a single-center study conducted in a large full-teaching hospital and the findings may not apply to other facilities. Second, the analysis might be underpowered to detect small but clinically significant differences in patient perception scores according to compliance with recording standards. Third, the authors could not investigate whether electronic medical record contributed to better compliance with recording standards and eventually higher patient perception scores.

Practical implications

– Because of the potential consequences of poor recording for patient safety, further efforts are warranted to improve the accuracy and completeness of documentation in medical records.

Originality/value

– A modest relationship exists between the quality of medical-record keeping and patient perception of hospital care.

Data recording aids in acute admissions

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.

Development of regional guidelines: the way forward for neonatal networks?

Successful development of regional guidelines can help to achieve unified neonatal practice

Implementing achievable benchmarks in preventive health: a controlled trial in residency education

PURPOSE

To evaluate the Preventive Health Achievable Benchmarks Curriculum, a multifaceted improvement intervention that included an objective, practice-based performance evaluation of internal medicine and pediatric residents' delivery of preventive services.

METHOD

The authors conducted a nonrandomized experiment of intervention versus control group residents with baseline and follow-up of performance audited for 2001-2004. All 130 internal medicine and 78 pediatric residents at two continuity clinics at the University of Alabama School of Medicine, Birmingham, participated. Performance of preventive care was assessed by structured chart review. The multifaceted feedback curriculum included individualized performance feedback, academic detailing by faculty, and collective didactic sessions. The main outcome was difference in receipt of preventive care for patients seen by intervention and control residents, comparing baseline and follow-up.

RESULTS

Charts were reviewed for 3,958 patients. Receipt of preventive care increased for patients of intervention residents, but not for patients of control residents. For the intervention group, significant increases occurred for five of six indicators in internal medicine: smoking screening, quit smoking advice, colon cancer screening, pneumonia vaccine, and lipid screening; and four of six in pediatrics: parental quit smoking advice, car seats, car restraints, and eye alignment (p < .05 for all). For control residents, no consistent improvements were seen. There was greater improvement for intervention than for control residents for four of six indicators in internal medicine, and two of six in pediatrics.

CONCLUSIONS

Using a multifaceted feedback curriculum, the authors taught residents about the care they provide and improved documented patient care.

Reviewing audit: barriers and facilitating factors for effective clinical audit

OBJECTIVE

To review the literature on the benefits and disadvantages of clinical and medical audit, and to assess the main facilitators and barriers to conducting the audit process.

DESIGN

A comprehensive literature review was undertaken through a thorough review of Medline and CINAHL databases using the keywords of "audit", "audit of audits", and "evaluation of audits" and a handsearch of the indexes of relevant journals for key papers.

RESULTS

Findings from 93 publications were reviewed. These ranged from single case studies of individual audit projects through retrospective reviews of departmental audit programmes to studies of interface projects between primary and secondary care. The studies reviewed incorporated the experiences of a wide variety of clinicians, from medical consultants to professionals allied to medicine and from those involved in unidisciplinary and multidisciplinary ventures. Perceived benefits of audit included improved communication among colleagues and other professional groups, improved patient care, increased professional satisfaction, and better administration. Some disadvantages of audit were perceived as diminished clinical ownership, fear of litigation, hierarchical and territorial suspicions, and professional isolation. The main barriers to clinical audit can be classified under five main headings. These are lack of resources, lack of expertise or advice in project design and analysis, problems between groups and group members, lack of an overall plan for audit, and organisational impediments. Key facilitating factors to audit were also identified: they included modern medical records systems, effective training, dedicated staff, protected time, structured programmes, and a shared dialogue between purchasers and providers.

CONCLUSIONS

Clinical audit can be a valuable assistance to any programme which aims to improve the quality of health care and its delivery. Yet without a coherent strategy aimed at nurturing effective audits, valuable opportunities will be lost. Paying careful attention to the professional attitudes highlighted in this review may help audit to deliver on some of its promise.

Essential dataset for ambulatory ear, nose, and throat care in general practice: an aid for quality assessment

OBJECTIVE

To describe the documentation of care for the usual range of ear, nose, and throat (ENT) problems seen in primary care as a basis for developing a computerised information system to aid quality assessment.

DESIGN

Descriptive study of the pattern of ENT problems and diagnoses and treatment as recorded in individual case notes.

SETTING

The primary health care centre in Mjölby, Sweden.

PATIENTS

Consultations for ENT problems from a 10% sample randomly selected from all consultations (n = 22,600) in one year. From this sample 375 consultations for ENT problems (16% of all consultations) by 272 patients were identified.

MAIN MEASURES

The detailed documentation of each consultation was retrieved from the individual records and compared with the data required for a computer based information system designed to help in quality management.

RESULTS

Although the overall picture gained from the data retrieved from the notes suggested that ENT care was probably adequate, the recorded details were limited. The written case notes were insufficient when compared with the details required for a computerised system based on an essential dataset designed to allow assessment of diagnostic accuracy and appropriateness of treatment of ENT problems in primary care.

CONCLUSION

There is a gap between the amount and the type of information needed for accurate and useful quality assessment and that which is normally included in case notes. More detailed information is needed if general practitioners' notes are to be used for regular quality assessment of ENT problems but that would mean more time spent on keeping notes. This would be difficult to justify.

IMPLICATIONS

The routine information systems used at this primary healthcare centre did not produce sufficient documentation for quality assessment of ENT care. This dilemma might be resolved by specially designed desktop computer software accessed through an essential dataset.

Does medical audit lead to explicit standards? Experience with thrombolysis in four UK hospitals

The setting of explicit standards against specific criteria is a recognized part of the medical audit cycle, but often in practice it has been neglected, implicit judgements being used instead. The conduct of a study to evaluate audit among physicians in four UK district general hospitals provided an opportunity to encourage the setting of explicit standards and observe the results. The subject chosen for audit by the participating physicians was the extent of use of intravenous thrombolysis in patients with suspected acute myocardial infarction (AMI). Standard setting was requested at initial peer review meetings held to review baseline results. This was followed up by a written request to lead consultants and subsequent telephone calls. Two out of the four participating hospitals set technical standards, which excluded patients with contra-indications from the denominator. The other two hospitals set population standards as requested, one with considerable reluctance and scepticism. Each hospital set separate standards for definite AMIs and for probable AMIs. Six out of the eight standards set were achieved in at least one of four audits conducted in each hospital. Time trends were difficult to interpret because of small numbers. The amount of discussion between the lead consultant and colleagues about standards was highly variable, but there was no clear relationship between the process for agreeing standards in a particular hospital and subsequent attainment.

Can admission notes be improved by using preprinted assessment sheets?

Inpatient medical notes often fail to record important details of patient history and findings on clinical examination. To overcome problems with content and legibility of notes we introduced preprinted notes for the admission of children to this hospital. The quality of the information recorded for 100 children whose admissions were clerked with the preprinted notes was compared with that recorded for 100 whose admissions were recorded with the traditional notes. All case notes were selected randomly and retrospectively from traditional notes written from April to October 1993 and from preprinted notes written from October 1993 to April 1994. The quality of information was assessed according to the presence or absence of 25 agreed core clinical details and the number of words per clerking. In admissions recorded with the preprinted notes the mean number of core clinical details present was significantly higher than those recorded with traditional notes (24.0 v 17.6, p < 0.00001). Admissions recorded with the preprinted notes were also significantly shorter (mean 144 words v 184 words, p < 0.0001). The authors conclude that information about children admitted to hospital is both more complete and more succinct when recorded using preprinted admission sheets.

National audit of acute severe asthma in adults admitted to hospital. Standards of Care Committee, British Thoracic Society

OBJECTIVE

To ascertain the standard of care for hospital management of acute severe asthma in adults.

DESIGN

Questionnaire based retrospective multicentre survey of case records.

SETTING

36 hospitals (12 teaching and 24 district general hospitals) across England, Wales, and Scotland.

PATIENTS

All patients admitted with acute severe asthma between 1 August and 30 September 1990 immediately before publication of national guidelines for asthma management.

MAIN MEASURES

Main recommendations of guidelines for hospital management of acute severe asthma as performed by respiratory and non-respiratory physicians.

RESULTS

766 patients (median age 41 (range 16-94) years) were studied; 465 (63%) were female and 448 (61%) had had previous admissions for asthma. Deficiencies were evident for each aspect of care studied, and respiratory physicians performed better than non-respiratory physicians. 429 (56%) patients had had their treatment increased in the two weeks preceding the admission but only 237 (31%) were prescribed oral steroids. Initially 661/766 (86%) patients had peak expiratory flow measured and recorded but only 534 (70%) ever had arterial blood gas tensions assessed. 65 (8%) patients received no steroid treatment in the first 24 hours after admission. Variability of peak expiratory flow was measured before discharge in 597/759 (78%) patients, of whom 334 (56%) achieved good control (variability < 25%). 47 (6%) patients were discharged without oral or inhaled steroids; 182/743 (24%) had no planned outpatient follow up and 114 failed to attend, leaving 447 (60%) seen in clinic within two months. Only 57/629 (8%) patients were recorded as having a written management plan.

CONCLUSIONS

The hospital management of a significant minority of patients deviates from recommended national standards and some deviations are potentially serious. Overall, respiratory physicians provide significantly better care than non-respiratory physicians.

Evaluation of medical audit

OBJECTIVE

To review current knowledge of the effectiveness of medical audit programmes as a whole and of specific interventions within these programmes, as a means of changing clinical behaviour. CRITERIA FOR INCLUSION AND EXCLUSION OF PUBLISHED REPORTS: Articles listed on Medline from 1985-92 with key words "quality assurance" or "medical audit", and "evaluation" and relevant references from these articles, and from recently published reviews and reports on medical audit, were included. Excluded were simple descriptions of audit activity, replications of previous work, and publication in a language other than English.

RESULTS

Evaluation of entire programmes of medical audit is unusual. Most reports concern specific interventions and focus particularly on the scientific and technical aspects of quality. These interventions may be classified by the means through which they attempt to achieve desired changes: patient characteristics; physician characteristics; administrative and organisational structures; and financial incentives.

CONCLUSIONS

Knowledge about effective methods of bringing about specific changes in clinical behaviour is rudimentary. Impact is highly dependent on local factors, so generalisation of results to other settings is difficult. More qualitative research is needed to define the local factors which influence results.

Palliative care in the community: setting practice guidelines for primary care teams

BACKGROUND

Previous studies have demonstrated deficiencies in palliative care in the community. One method of translating the results of research into clinical practice, in order to produce more effective health care, is the development of clinical guidelines. Setting standards for such care has been performed by care teams in both hospital and hospice settings but not in primary care.

AIM

This study set out to develop guidelines for primary care teams to follow in the provision of palliative care in the community using facilitated case discussions with the members of such teams, as a form of internal audit.

METHOD

Five practices were randomly chosen from the family health services authority medical list. Meetings between the facilitators and primary care teams were held over a period of one year. The teams were asked to describe good aspects of care, areas of concern and suggestions to improve these, in recent cases of patient deaths.

RESULTS

In total 56 cases were discussed. All practices felt that cohesive teamwork, coordinated management, early involvement of nursing staff and the identification of a key worker were essential for good terminal care. Concerns arose in clinical and administrative areas but the majority were linked to poor communication, either between patient and professionals within the primary care team or between primary and secondary care. All the positive aspects of care, concerns and suggestions were collated by the facilitators into guidelines for teams to refer to from the initial diagnosis of a terminal illness through to the patient's death and care of the relatives afterwards.

CONCLUSION

Developing multidisciplinary as opposed to medical guidelines for palliative care allows primary health care teams to create standards that are acceptable to them and stimulates individuals within the teams to accept responsibility for initiating the change necessary for more effective care. The process of facilitating teams to discuss their work allows for recognition and respect of individuals' roles and more importantly provides shared ownership, an important contributory factor in the implementation of guidelines.

Use of a pro forma for head injuries in the accident and emergency department--the way forward

The aim of this study was to assess the quality of documentation of head-injured patients seen in three accident and emergency (A&E) departments using a specially designed head injury pro forma. A 4-week prospective study of a single head injury pro forma was followed by a second similar study with an improved version (two head injury pro formas, one for young children and babies, the other for older children and adults). The main outcome measures were the degree of completion of the pro forma and questionnaire responses from receptionists, nurses and doctors. A total of 1260 patients had their details completed on the pro forma in both studies. Compared with standard hand written A&E notes, the degree of completion of clinical details specific to the head injury were high, eg. over 95% for symptoms. The pro forma was generally well received by A&E staff, particularly after recommended improvements were made, and the majority of staff felt it should be introduced permanently into the A&E department. Concern about its use in cases of very minor head injury and multiple injuries were raised. As well as improved documentation, the pro forma facilitates the process of audit and may have an important role to play in information technology and computers in the future.