scholarly journals Improving standards in clinical record-keeping

2006 ◽  
Vol 12 (4) ◽  
pp. 280-286 ◽  
Author(s):  
Ian Pullen ◽  
John Loudon
Keyword(s):  
Clinical Care ◽  
Good Practice ◽  
General Medical Council ◽  
Medical Council ◽  
Record Keeping ◽  
Fit For Purpose ◽  
Clinical Tools ◽  
Reasons For Decisions ◽  
Clinical Records

Clinical records are the most basic of clinical tools. Aggregated, they form a permanent account of individual considerations and the reasons for decisions. Essential for effective communication and good clinical care, they are often accorded low priority, are poorly maintained and not readily available. Independent inquiries, health ombudsmen's reports and the courts have repeatedly criticised the quality of records and the resulting failings of care. Most advice from professional bodies, indemnity organisations and the General Medical Council is extremely brief and confined to individual entries in the record. Patient safety and the demands of clinical governance make change essential. This article draws together standards and concludes with some good practice points for a fit-for-purpose, structured, multidisciplinary record to support good care and protect the interests of patients and clinicians. These principles should be equally applicable to electronic records.

scholarly journals 683 Minimum Data Set in Documentation of Operative Findings in Diagnostic Laparoscopy

2021 ◽  
Vol 108 (Supplement_6) ◽  
Author(s):  
S Nakhuda ◽  
A Liyanage ◽  
R Satchidanand
Keyword(s):  
General Medical Council ◽  
Second Phase ◽  
Medical Council ◽  
Data Set ◽  
Record Keeping ◽  
Operative Note ◽  
Quality Of Patient Care ◽  
Operative Findings ◽  
Operative Notes

Abstract Aim Legible, accurate and clear documentation of operative findings is an integral part of patient safety, with guidelines from the Royal College of Surgeons and General Medical Council having clear standards of operative note-keeping. However, a substantial variation in the quality and accuracy of these notes can still be observed in everyday practice. We recognised the significance of a minimum set of data in operative record keeping for diagnostic laparoscopies as a standard, to improve quality and uniformity. Method We retrospectively examined 50 diagnostic laparoscopies over 6 months and assessed their operative notes against the guidelines described above. We found that there was no clear uniformity in reporting, subjective descriptions used and a significant amount of under-reporting of operative findings. We developed a proforma as a substitute for the documentation of operative findings which was implemented in the second phase of the audit and the compliance was assessed over a 3-month period. Results We found that usage of the proforma was limited (9/22), however those notes using the proforma were compliant with the guidelines for operative note keeping, to a much higher degree than those without. All the operative findings were documented for 100% of those notes which used the proforma; for those using freehand notes, only the appendix was identified to the same standard, which is explained by all diagnostic laparoscopies proceeding to appendicectomies. Conclusions Using a proforma as standard record keeping can improve the quality and accuracy of operative notes and thereby help improve safety and quality of patient care.

scholarly journals Learning disability market position statements, are they fit for purpose?

2017 ◽  
Vol 22 (4) ◽  
pp. 198-205 ◽  
Author(s):  
Sarah Broadhurst ◽  
Keri Landau
Keyword(s):  
Learning Disabilities ◽  
Learning Disability ◽  
Good Practice ◽  
Market Position ◽  
Content Type ◽  
Fit For Purpose ◽  
Potential Impact ◽  
Senior Officers ◽  
Market Shaping

Purpose The purpose of this paper is to review whether current learning disability market position statements (MPS) are actually helping to shape the market and explore their implications for people with learning disabilities and their families. Design/methodology/approach Published learning disability MPS were identified via the Institute of Public Care’s MPS database. The quality of the MPS was analysed using a good practice checklist developed by a range of stakeholders. Findings Learning disability MPS are not currently fit for purpose. They demonstrate that local authorities are not fully engaging in their market-shaping duties, as required under The Care Act 2014. It is suggested that this is in part due to the lack of recognition that market shaping is a council-wide responsibility and can only be successful if senior officers across the council (and their partners) acknowledge this and are held accountable. Unless this happens, people with learning disabilities will continue to lack the enablers that support them to lead the lives they choose in their communities. Originality/value This is the first review of the quality and potential impact of learning disability MPS.

Principles and Standards of Anaesthetic Monitoring

2011 ◽  
Author(s):  
Patrick Magee ◽  
Mark Tooley
Keyword(s):  
General Medical Council ◽  
International Standards ◽  
World Federation ◽  
Medical Council ◽  
The World ◽  
Minimum Requirements ◽  
Principles And Standards ◽  
Human Failure ◽  
Training Programmes

The World Federation of Societies of Anaesthesiology (WFSA) adopted standards relating to the safe practice of anaesthesia in 1992 and such standards had already been proposed by a number of countries in order to cut the morbidity due to anaesthesia itself. In the modern era it is easy to forget that historically anaesthesia and surgery did indeed have associated morbidity and mortality and there was very little assistance from technology to monitor patients. The evolution of these standards is based on two main requirements of monitoring. The first is to record anticipated deviations from normal values, which require accurate measurement to ensure patient safety. The second is to warn of unexpected, life-threatening events that, by definition, occur without warning, and could affect the fit, young patient as easily as the old and infirm. All international standards stress the importance of the continual presence of a fully trained and accredited anaesthetic person, and one Australian study demonstrated that many mishaps occur in the absence of such a person [Runciman 1988]. This applies to general and regional anaesthesia, sedation and recovery. Because perceptions of safety and standards vary throughout the world, despite the presence of an International Standards Organisation, debate about the minimum requirements for monitoring continue. Central to the maintenance of these standards is the quality of persons entering the specialty, the quality of training programmes, and the continuing education of specialists throughout a professional lifetime [Sykes 1992]. It is difficult to determine with certainty the effect that additional technological monitoring has on safety. One clear example is the inability of the trained human eye to detect cyanosis, this human failure occurring maximally at 81–85% oxygen saturation. Clearly, the pulse oximeter has improved the quality of cyanosis detection. Numerous studies all over the world have shown that mortality due to anaesthesia itself fell significantly between the 1950s and the 1980s, by which time extensive technological monitoring was being introduced, and training programmes had been very much improved. Utting [1987] reviewed 750 cases of death and cerebral damage reported to the British General Medical Council between 1970 and 1982 that were thought to be the result of errors in technique.

scholarly journals Individual appraisal for senior medical staff

2001 ◽  
Vol 25 (5) ◽  
pp. 166-169 ◽  
Author(s):  
Salwa Khalil ◽  
Elizabeth Parry ◽  
Nick Brown ◽  
Femi Oyebode
Keyword(s):  
Medical Staff ◽  
Clinical Care ◽  
General Medical Council ◽  
Component Part ◽  
Medical Council ◽  
Appraisal System ◽  
Public Attention ◽  
Medical Interventions ◽  
The Us ◽  
The Uk

There is public concern about medical errors. In Britain, the Bristol Inquiry is the paradigmatic example that focuses professional and public attention on the safety of medical interventions. In the US the Institute of Medicine's recent report To Err is Human: Building a Safer Health System (1999) was widely seen on both sides of the Atlantic as confirming what most already feared, that medical interventions were accompanied by unacceptably high levels of preventable harms (Barach & Small, 2000). The response to these public concerns has been multifold. In the UK clinical governance was introduced in April 1999, principally to focus attention on continuously improving the quality of clinical care. At the same time, the arrangements for the registration of doctors by the General Medical Council (GMC) was under review and there was an expectation that NHS trusts would bring consultants, who hitherto had been regarded as independent practitioners outside any supervisory system or arrangement, within an appraisal system. It has become clear that this appraisal system will be a component part of the GMC's revalidation of doctors (GMC, 2000). What is clear is that these varying systems are designed to restore public trust by providing an open process, which has the confidence of the profession, management and public alike. In this paper we aim to discuss the historical development of appraisal as a system for reviewing the performance of individual practitioners, suggest a method for appraising senior medical staff and finally to discuss the limitations and problems inherent in the introduction of such a system.

Documentation and Record Keeping Are Burdens to Be Completed as Quickly as Possible

2019 ◽  
pp. 117-122
Author(s):  
Jeffrey E. Barnett ◽  
Jeffrey Zimmerman
Keyword(s):  
Mental Health ◽  
Quality Care ◽  
Mental Health Practitioners ◽  
Record Keeping ◽  
Legal Obligations ◽  
Health Practitioners ◽  
Care Information ◽  
Clinical Records

Documentation and record keeping are not known as the most enjoyable aspects of being a mental health clinician. Yet, as this chapter explains, they play a vital and important role in meeting one’s ethical and legal obligations. Further, it is explained how timely, thorough, effective documentation can help mental health practitioners to fulfill their obligation to provide the highest possible quality of care. Information is also provided on how clinical records may be needed in the future, and the risks associated with minimal or absent documentation. The role of documentation as a risk management strategy, to meet legal requirements, and to assist in providing high-quality care are each addressed. Specific guidance is provided on the needed components of effective documentation.

Structured learning for clinical ethics in anaesthesia

2016 ◽  
Vol 11 (4) ◽  
pp. 200-209
Author(s):  
Sri Logarajah ◽  
Sue Roff
Keyword(s):  
Medical Practice ◽  
Clinical Ethics ◽  
Ethics Education ◽  
Good Practice ◽  
General Medical Council ◽  
Structured Learning ◽  
Medical Council ◽  
Ethical Practice ◽  
Good Medical Practice ◽  
Education Decision

The ‘SLICE’ model for Structured Learning in Clinical Ethics provides a template to help medical professionals identify their own “moral compass” to provide guidance in complex ethical areas. The model has five domains – Conscience, Compliance, Concurrence, Conversation and Conversion. The use of ‘SLICE’ model as a tool for ethics education has been described in various undergraduate and postgraduate settings. These include teaching ethical aspects of transplantation; legislation for undergraduates and consent in paediatric anaesthesia. Its use as tool for teaching reflective ethical practice has been recently described demonstrating the potential of the SLICE model for supporting appraisal and professional development. In this article, we explore the suitability of the SLICE model to provide a general framework encompassing all the requirements for Ethical Clinical practice in anaesthesia. Good Medical Practice guidance produced by the General Medical Council and guidance provided jointly by the Royal College of Anaesthetists and Association of Anaesthetists of Great Britain and Ireland is used as the foundation for developing this framework. The Good Practice Guide for anaesthetic departments provides a solid ethical frame work for interpreting and applying Good Medical Practice guidance by the General Medical Council. Tools such as the SLICE model complement the guides produced by the professional organisations by providing a choice of different methods to facilitate education, decision making and reflective practice.

scholarly journals Addressing uncertainties about the effects of treatments offered to NHS patients: whose responsibility?

2007 ◽  
Vol 100 (10) ◽  
pp. 440-441 ◽  
Author(s):  
Iain Chalmers
Keyword(s):  
Patient Safety ◽  
General Medical Council ◽  
Medical Council ◽  
Promote Patient Safety

‘You must work with colleagues and patients to maintain and improve the quality of your work and promote patient safety. In particular you must … help to resolve uncertainties about the effects of treatments.’ General Medical Council 1

scholarly journals A Historical Look at the Indian Healthcare Professionals in the NHS

2019 ◽  
Vol 12 (1) ◽  
pp. 19-21
Author(s):  
Balmukind Bhala ◽  
Aruna Bhala ◽  
Neeraj Bhala
Keyword(s):  
Medical Education ◽  
Medical Service ◽  
Indian Subcontinent ◽  
General Medical Council ◽  
Healthcare Sector ◽  
Medical Council ◽  
Indian Medical ◽  
The Government ◽  
The Uk

Doctors and nurses from the Indian subcontinent have been working in the UK healthcare sector for over a 100 years. Initially only open to Europeans, Indians were allowed to enter the Indian Medical Service (IMS) in 1855, although the requisite was that they had to sit exams based in London and had to be registered with the General Medical Council (GMC). At the time there were many schools training Indian doctors, but only as licentiates. In relation to medical education, through pressure applied by the IMS, indigenous courses for the training of Indian doctors were abolished and several medical colleges, modelled along western pedagogic styles, were established. The staff of all these colleges were appointed from the IMS and their methods of instruction were virtually indistinguishable from those practised in England and Scotland. Indian degrees were recognised in 1892 by the GMC and this recognition persisted until 1975, with a short interlude in the mid-1930s when there was a dispute between the GMC and the Government of India about the quality of Indian medical education. 1

scholarly journals 1469 Audit of Clinical Notes Filing in Vascular Surgery

2021 ◽  
Vol 108 (Supplement_6) ◽  
Author(s):  
M Griffiths ◽  
A Perusseau-Lambert ◽  
A Bush ◽  
D Mittapalli
Keyword(s):  
Vascular Surgery ◽  
Medical Practice ◽  
Royal College ◽  
Quality Care ◽  
General Medical Council ◽  
Medical Council ◽  
Chronological Order ◽  
Record Keeping ◽  
Clinical Notes ◽  
Good Medical Practice

Abstract Aim Assess the correctness of patient's notes filing following the Royal College of Physicians, Record Keeping Standards, and the General Medical Council, Good Medical Practice, guidance: medical notes must be filed in the correct section, in a chronological order, three key identifiers on each page. Method Over 3 months, the general surgical wards, using case notes and those using folders for the current admission were assessed to identify loose notes. The vascular surgery patients’ notes were reviewed for the following criteria: not loose, filed in the correct section, in chronological order, and had three key identifiers. Results Surgical wards using case notes had 28.6% of the notes filed (n = 21) compared with 78.9% filed on wards with admission folders (n = 57). Within vascular surgery (n = 15), 13.3% had all notes filed, 20% were in chronological order, 6.7% had notes filed in the correct section, and 20% had key identifiers on every page. Conclusions The filing of case notes on the vascular ward resulted in loose notes more than other wards that use admission folders. To resolve this, “Admission Folders” were introduced (alongside full case notes) to assist with filing and label sheets used to assist with fast identification of current admission documents. After implementation of Admission Folders, the staff found notes easier to access and follow, according to the staff surveys, and notes were correctly filed and given identifiers, ensuring continued quality care for the patients.

scholarly journals Clinical standards and the wider quality agenda

2000 ◽  
Vol 24 (3) ◽  
pp. 85-89 ◽  
Author(s):  
Paul Lelliott
Keyword(s):  
Medical Practice ◽  
General Public ◽  
Self Regulation ◽  
General Medical Council ◽  
Medical Council ◽  
Medical Practitioners ◽  
Professional Self ◽  
The Media ◽  
The Government

There is an unprecedented level of interest among the general public, the media and politicians in the quality of treatment and care provided by the NHS. Traditional methods for upholding the quality of medical practice, through professional self-regulation, are under attack. The General Medical Council (GMC) has responded by voting to introduce a process of revalidation for medical practitioners. If this is not seen to succeed, the Government could take this responsibility away from the GMC, and the Medical Colleges and Faculties.

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