EP.FRI.57 Audit of Medical Records on Structure and Content of T&O Documentation

The aim of the audit was to assess if Trauma & Orthopaedic admission documentation and record-keeping met the national standards. Standards used included the ‘Royal College of Physicians-Generic Record Keeping Standards 2, 4, 6, 10’ and ‘Professional Records Standards Body, Section 2 Admission Record’. Seventeen admission criteria and eight documentation criteria where audited from the respective standards. Retrospective data were collected using A&E clerking documents, GP referral letters, admission clerking proformas and continuation notes from hospital admission. Initial data showed that only 41% of pages of documentation had appropriate patient identification details listed. Of the 17 admission criteria audited, only 7 criteria scored above 90%. The major downfalls were in vital signs (38%) and assessment scales i.e. Abbreviated Mental Test Score (18%) and venous thromboembolism assessment (32%). With regards to subsequent separate entries, the main failure was entries not listed in chronological order (48%), with only two criteria scoring above 90% (entries dated and legibility). Following the implementation of an updated admission proforma and education on documentation; only 5 of the 17 admission criteria scored 90% or above. However, 46% of pages had the correct patient identification details on admission. On subsequent ward entries, 7 out of the 8 sections had improved, with 62% of notes in chronological order. Furthermore, 4 out of the 8 documentation criteria scored above 90%. Informing staff on correct documentation helped improve doctors’ entries in patients’ notes. Improvements in the admission proforma need to be made to help meet record-keeping standards.