Assessing the Correct Documentation of Time and Physician Information on Medical Records in the Emergency Department of Queen's Hospital: An Audit and Re-audit.

BACKGROUND

Medical records are confidential medical and legal documents describing a patient's contact with a healthcare facility. The quality of documentation has been found to be lower in settings of high patient volume and complex cases, such as the emergency department (ED). The variety and number of healthcare professionals involved in the care of the patient also negatively affect the quality of documentation. The aim of this paper is to present the results of an audit and re-audit conducted in the ED of Queen's Hospital, Romford, to assess ED record documentation against General Medical Council (GMC) and Royal College of Physicians (RCP) standards.

METHODS

For the audit, all records of patients who were discharged from the ED of Queen's Hospital in one day were reviewed and evaluated on whether they have a date, time, the full name of the physician, their GMC number, and signature documented, as per GMC and RCP official guidelines. No medical information or patient data were recorded. After the implementation of the change aiming to raise awareness of ED staff, a new sample was collected two months later, and the same parameters were assessed against the set standards.

RESULTS

Results of the audit showed a low percentage of documentation of all parameters, especially of GMC number and signature. After the presentation of the results and implementation of change, the results of the re-audit demonstrated significant raise in all percentages, with a relative improvement of 40% regarding the recording of GMC number and 65% regarding signature. However, the documentation of these two parameters remained low and below acceptable levels.

DISCUSSION

The re-audit results underline that the low compliance was significantly improved after the implementation of measures aiming to increase correct documentation awareness among ED staff. However, to maintain and even raise the level of current practice, additional systematic measures need to be put into action.