STAMPING OUT BAD DOCUMENTATION: A COMPLETE AUDIT CYCLE

1. STAMPING OUT BAD DOCUMENTATION: A COMPLETE AUDIT CYCLE Gemma Gough & Katie Mageean ST1 Paediatrics, Royal United Hospital, Bath dr.g.gough@googlemail.com; katie.mageean@nhs.net AIM: To audit current documentation standards in the paediatric department (Children’s Ward and NICU) of the Royal United Hospital, Bath, to make appropriate recommendations and assess their effectiveness through re-audit. BACKGROUND: Accurate documentation in patient notes is a legal requirement and is vital for effective communication, and ultimately good patient care. Its importance is highlighted as an essential aspect of Good Medical Practice by the General Medical Council 1. 4. Recommendations implemented: Personalised stamps introduced with Name & GMC No. 1& 5. Criteria and standards set/revised: 9 criteria based on guidance from professional bodies1-3 and local trust policy. Standards set at 100% for each criteria. RESULTS: • DISCUSSION: • Cycle 1: No entry fulfilled all 9 criteria • Weakest areas were 3 points of patient ID (on the front and back of the page) and GMC No. • Audit presented in departmental meeting to raise awareness, and recommendations made: • Personalised name/GMC No. stamps (bought voluntarily by a small number of junior doctors) • Patient ID labels in all patient notes (not implemented prior to cycle 2, but under discussion) • 3 points of patient ID required on front of page only, in line with local trust guidance • Cycle 2: 7% of entries fulfilled all 9 criteria with improvement in all areas except bleep/contact no. • Greatest improvements seen in patient ID and GMC No. • Further recommendations made to provide all clinicians with personalised stamps, continue discussion regarding provision of patient ID labels, and maintain awareness of documentation standards through regular re-audits and discussion. METHOD: The Audit Cycle 3&7. Results and Feedback: Audit data presented to paediatric department, recommendations agreed upon. 2&6. Data collection: All inpatient notes audited (5 entries from each set of notes); each entry assessed against set criteria. Table 1. Results for fulfilment of each criteria, expressed as a percentage of all entries Compliance (%) 90-100 75-89 <75 CONCLUSION: Documentation in the paediatric department was below ideal standards, which could have a significant impact on patient care. The introduction of personalised stamps and raising awareness of the importance of documentation has improved documentation standards in the department. The trust is now providing stamps for all new starters. This will contribute to continued improvement in documentation and patient safety. References: 1Good Medical Practice guidelines (2013) www.gmc-uk.org/guidance/good_medical_practice.asp 2MPS Factsheets- Medical Recordswww.medicalprotection.org/uk/england-factsheets/medical-records 3Generic medical record keeping standards- Royal College of Physicianswww.rcplondon.ac.uk/resources/generic-medical-record-keeping-standards