Safety comes first: Are doctors attentive enough to their initial clinical assessment notes?

Hdl Handle:
http://hdl.handle.net/10147/307048
Title:
Safety comes first: Are doctors attentive enough to their initial clinical assessment notes?
Authors:
Daly, C; Callanan, I; Butler, M
Publisher:
Irish Medical Journal (IMJ)
Journal:
Irish Medical Journal (IMJ)
Issue Date:
Dec-2013
URI:
http://hdl.handle.net/10147/307048
Abstract:
Accurate hospital admission/initial history and physical examination [H&P] notes are vital to support patient care. We aimed to assess the quality of H&P notes and to compare medical/surgical, and inpatient/outpatient H&P notes. A cross-sectional study examined 154 initial H&P notes for the adherence to a standard protocol in a tertiary referral hospital. 134 doctors (87.1%) adhered to the correct layout in accordance with the standard. Only 77 doctors (50%) recorded the names of the patientâ s medications. 106 (68.8%) documented the allergy status. Six doctors (3.9%) omitted an objective record of their own identity. Surgeons were superior at recording admission type (p=0.0001) and past surgical history (p=0.002) only. The data in this study show that the standard of completeness of the H&P documentation among doctors is suboptimal. We recommend the introduction of a standardised H&P template to reduce errors
Item Type:
Article
Language:
en
Keywords:
CLINICAL GOVERNANCE; MEDICAL ERRORS; PATIENT SAFETY
Local subject classification:
NOTE TAKING

Full metadata record

DC FieldValue Language
dc.contributor.authorDaly, Cen_GB
dc.contributor.authorCallanan, Ien_GB
dc.contributor.authorButler, Men_GB
dc.date.accessioned2013-12-18T14:28:01Z-
dc.date.available2013-12-18T14:28:01Z-
dc.date.issued2013-12-
dc.identifier.urihttp://hdl.handle.net/10147/307048-
dc.description.abstractAccurate hospital admission/initial history and physical examination [H&P] notes are vital to support patient care. We aimed to assess the quality of H&P notes and to compare medical/surgical, and inpatient/outpatient H&P notes. A cross-sectional study examined 154 initial H&P notes for the adherence to a standard protocol in a tertiary referral hospital. 134 doctors (87.1%) adhered to the correct layout in accordance with the standard. Only 77 doctors (50%) recorded the names of the patientâ s medications. 106 (68.8%) documented the allergy status. Six doctors (3.9%) omitted an objective record of their own identity. Surgeons were superior at recording admission type (p=0.0001) and past surgical history (p=0.002) only. The data in this study show that the standard of completeness of the H&P documentation among doctors is suboptimal. We recommend the introduction of a standardised H&P template to reduce errorsen_GB
dc.language.isoenen
dc.publisherIrish Medical Journal (IMJ)en_GB
dc.subjectCLINICAL GOVERNANCEen_GB
dc.subjectMEDICAL ERRORSen_GB
dc.subjectPATIENT SAFETYen_GB
dc.subject.otherNOTE TAKINGen_GB
dc.titleSafety comes first: Are doctors attentive enough to their initial clinical assessment notes?en_GB
dc.typeArticleen
dc.identifier.journalIrish Medical Journal (IMJ)en_GB
dc.description.fundingNo fundingen
dc.description.provinceLeinsteren
dc.description.peer-reviewpeer-reviewen
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