Clinical audit and standardised follow up improve quality of documentation in diabetes care.

AIM

High quality of follow up data is important in improving diabetes care. Our aim was to improve quality of documentation and diabetes care by using a combination of clinical audit and standardised follow up.

METHODS

During 2 months in 1991-2 the records of all patients attending the diabetes clinic were reviewed. Quality of documentation was assessed for diabetic medication, hypoglycaemia, glycoprotein level, body weight, smoking history, blood pressure, albuminuria, visual acuity, fundi examination, neuropathy, foot inspection, peripheral vascular disease, cerebrovascular disease, ischaemic heart disease and serum cholesterol. For all parameters results and documented interventions were noted. A standardised follow up form was then introduced and the audit was repeated in 1993-4.

RESULTS

156 patients were included in 1991-2 and 138 in 1993-4. There were no differences between the two groups with regards to baseline demographic data. Follow up data for 10 parameters were between 1.15 and 5.35 times more likely to have been recorded in 1993-4. The other 5 items were as likely to have been recorded in 1991-2 as in 1993-4. However, the differences between the two audits were less convincing and inconsistent for number of abnormalities detected in each group and whether abnormal results led to documented actions.

CONCLUSIONS

These results show that repeated audit and standardised follow up can improve the quality of documentation of diabetic follow up, but that this does not necessarily mean that a higher proportion of abnormal results will be detected and acted upon. Additional practice protocols may be necessary to achieve this.