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Safety comes first: Are doctors attentive enough to their initial clinical assessment notes?
Daly, C Callanan, I Butler, M
Daly, C
Callanan, I
Butler, M
Authors
Advisors
Editors
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Departments
Date
2013-12
Date Submitted
Keywords
CLINICAL GOVERNANCE
MEDICAL ERRORS
PATIENT SAFETY
MEDICAL ERRORS
PATIENT SAFETY
Other Subjects
NOTE TAKING
Subject Mesh
Planned Date
Start Date
Collaborators
Principal Investigators
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Article7123.pdf
Adobe PDF, 9.42 KB
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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
Language
en