Medical Record Keeping in Paediatric Surgery: Re-Audit

Aims - To re-audit the quality of medical record keeping in the paediatric surgery department against established standards set by the GMC and by the Royal College of Surgeons. To compare our data with that of a preliminary audit conducted in 2012. Methods - 21 sets of patient notes were examined over a four week period in January 2014, using both prospective and retrospective data collection methods depending on the notes available. Using the modified CRABEL score as set out by the Royal College of Surgeons, the quality of the initial clerking and up to five subsequent entries in the notes were assessed per patient.  Results - Regarding initial clerkings, patient name and number were present in only 43% of entries, compared to 94% at initial audit. Referral source was documented in only 38% and Consultant on call documented in 19% of entries, compared to 72% and 50% respectively at initial audit. Clinician name, post and bleep number was complete in 48% of entries, the most common omission being bleep number (missing in 46%). Regarding subsequent entries in the notes, investigation results were documented in 42% of entries, compared to 91% at initial audit. Clinician details were complete in 48% of entries, compared to 28% at initial audit, with the most common omission being clinician name and post (missing in 49%). Conclusions - This re-audit demonstrates some improvement in the medical record keeping practice in the paediatric surgery department with regard specifically to entries in the notes subsequent to the initial clerking. However, it also highlights important declines in quality of medical record keeping since the initial audit two years previously, resulting in recommendations including clinician details stamps, bleeps for all registrars and inclusion of documentation standards as part of induction for new juniors on the ward.