A J Diver, B F Craig
Fracture Clinic, Department of Orthopaedic Surgery, Royal Victoria Hospital, Belfast
Correspondence to: Mr A J Diver, Flat A5 William Gunn House, 50 Lawn Road, Hampstead, London NW3 2XA Email: andrewjdiver@hotmail.com
SMJ 2005 50(3): 101-102
Abstract
The authors worked in a busy regional fracture unit, where it was noted that important data was being omitted from medical notes. In an attempt to improve on this, an admission proforma was formulated. This was designed to be easily and quickly completed. Notes were audited on two separate weeks, the first before, and the second after introduction of the proforma. The overall results demonstrate statistically significant improvements in documentation with a proforma, and concur with the limited previous literature in this area.1-4
Introduction
In the era of increasing shift rotas, doctors often find themselves presenting patients they have never met on the morning round. In such instances there is a need for thorough clinical notes to enhance the efficient retrieval of salient information. In our institution, it was noted that important information was often omitted from notes. This ranged from basic data such as date of birth and hospital number to more important details, including past medical history, previous level of function, and general examination. A prospective audit of clinical note-taking was designed, to study the impact of the introduction of an admission proforma.
Methods
A proforma was developed with audited headings detailed in Table I. Further headings included: •other injuries, •current symptoms, •medications / allergies, •specific trauma examination, and •whether any fractures were open or closed. An option to write on the reverse side of the proforma was indicated. Audited items were chosen because of their observed tendency to be omitted from documentation. A single observer audited a total of 75 admission records in a structured manner. The collection of data was anonymous with respect to the admitting doctor and none had been admitted by the observer. Before and during week one, the other senior house officers were unaware of the audit. At the end of week one, they were informed, and agreed to participate by completing the proforma for every admission thereafter. There was a period of five weeks between the first and second data collections. Data was analysed using Fisher’s Exact Test, and a p value of less than 0.05 accepted as a statistically significant result. Results Admission records were audited for 38 free text records and 37 proforma records. Table I demonstrates that, for the majority of data, there was improvement in documentation following introduction of the proforma. In many instances, this was statistically significant. The most striking improvement is seen with previous level of function which increased almost seven fold in the proforma group (p<0.0001). Attention is drawn to the poor documentation of general examinations, at approximately 60% in both groups. This may be partly explained by the fact that, following senior house officer assessment (largely trauma-based), a junior house officer would perform a more medically detailed admission on the ward.
Discussion
Audit has previously highlighted the omission of important patient data from medical records.1 A small number of earlier studies have demonstrated improvement in medical notes following introduction of a structured admission proforma.2-4 O’Driscoll and colleagues recently found that a proforma improved the quality and quantity of admission notes.3,4 They also reported that it increased the speed of data retrieval and was preferred by most staff who used it. Overall, there remains very limited literature in this important area.
When we encounter a particularly demanding day at work, thorough documentation in patient notes is often the first duty to suffer. However, from clinical and medico-legal standpoints, few would argue that it is one of our most important duties. Nylenna recognised that incomplete records and lack of information will always be held against the doctor in complaints and legal procedures.5 Whilst we enjoy the freedom of a blank continuation sheet, we occasionally forget to document simple facts which may well have been established from the history and examination. This paper highlights the role of the admission proforma as a prompting tool to minimise such error, and demonstrates significant improvements following its introduction.
The proforma was developed based on the salient information necessary for a doctor, working nights, to present the case to the consultant in the morning. In devising the audit, the importance of documenting demographic items, such as date of birth and hospital number was recognised, as well as clinical details including past medical history, previous level of function, and general systemic examination. These latter items are particularly important in, for example, an elderly lady with a fractured femur. The management decision would be influenced not only by xray appearances, but also her previous health and mobility.
The limitations of the study are acknowledged. Firstly, the sample sizes are relatively small, but not to the extent that the results should be negated. Secondly, it can be appreciated that the junior doctors were aware of the audit during the second week of data collection, potentially influencing results for the second week. However, the nature of a proforma ensures that it is quite difficult to accidentally omit information, except through blatant oversight, and this is the fundamental advantage of a proforma. Therefore the results are unlikely to be due to the Hawthorne effect alone (altered behaviour in those who are aware they are being studied). Lastly, there may have been an element of deferring medical aspects of the assessment for the junior house officer. Nevertheless, the items on the proforma were deemed to represent the minimal information necessary for a comprehensive senior house officer trauma assessment.
The authors propose that proformas should be used more widely by junior doctors, and by other members of staff. The standard nursing admission tends to follow a proforma basis, and perhaps the medical and nursing admissions should be amalgamated so that basic information is already documented before the doctor sees the patient. With the current high level of patient turnover in hospitals, any tool which improves efficiency, and minimises important omissions from notes, should be seriously considered for universal application.
REFERENCES
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