Medical Record Documentation among Interns: A Prospective Quality Improvement Study

Hdl Handle:
http://hdl.handle.net/10147/558654
Title:
Medical Record Documentation among Interns: A Prospective Quality Improvement Study
Authors:
Owen, JM; Conway, R; Silke, B; O’Riordan, D
Publisher:
Irish Medical Journal
Journal:
Irish Medical Journal
Issue Date:
Jun-2015
URI:
http://hdl.handle.net/10147/558654
Abstract:
Comprehensive record keeping is a key aspect of medical practice. The National Hospitals Office (NHO) and Irish Medical Council (IMC) have published guidelines in this area. A prospective audit of 100 patients assessed by interns was performed to quantify adherence with these guidelines followed by an educational session and email reminders. Adherence was reassessed in an incidental manner. Compliance was recorded in a number of areas including the reason for review and documentation of a plan both 98 (98%). However less than half of interns recorded the patientâ s name, background history or their impression of the case. Only 31(31%) noted the patientâ s MRN and only 1(1%) the information they gave to the patient. Significant improvements following the intervention were found, however significant deficits remained in a number of areas including the noting of an impression of the case 62(62%) and information given to patients 18(18%). Suboptimal documentation can be improved through education and clinical auditing.
Item Type:
Article
Language:
en
Keywords:
MEDICAL RECORD
Local subject classification:
RECORD KEEPING

Full metadata record

DC FieldValue Language
dc.contributor.authorOwen, JMen
dc.contributor.authorConway, Ren
dc.contributor.authorSilke, Ben
dc.contributor.authorO’Riordan, Den
dc.date.accessioned2015-06-29T14:43:28Zen
dc.date.available2015-06-29T14:43:28Zen
dc.date.issued2015-06en
dc.identifier.urihttp://hdl.handle.net/10147/558654en
dc.description.abstractComprehensive record keeping is a key aspect of medical practice. The National Hospitals Office (NHO) and Irish Medical Council (IMC) have published guidelines in this area. A prospective audit of 100 patients assessed by interns was performed to quantify adherence with these guidelines followed by an educational session and email reminders. Adherence was reassessed in an incidental manner. Compliance was recorded in a number of areas including the reason for review and documentation of a plan both 98 (98%). However less than half of interns recorded the patientâ s name, background history or their impression of the case. Only 31(31%) noted the patientâ s MRN and only 1(1%) the information they gave to the patient. Significant improvements following the intervention were found, however significant deficits remained in a number of areas including the noting of an impression of the case 62(62%) and information given to patients 18(18%). Suboptimal documentation can be improved through education and clinical auditing.en
dc.language.isoenen
dc.publisherIrish Medical Journalen
dc.subjectMEDICAL RECORDen
dc.subject.otherRECORD KEEPINGen
dc.titleMedical Record Documentation among Interns: A Prospective Quality Improvement Studyen
dc.typeArticleen
dc.identifier.journalIrish Medical Journalen
dc.description.fundingNo fundingen
dc.description.provinceLeinsteren
dc.description.peer-reviewpeer-reviewen
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