How to keep good clinical records

Mathioudakis, Alexander G.; Roušalová, Ilona; Gagnat, Ane Aamli; Saad, Neil J.; Hardavella, Georgia

doi:10.1183/20734735.018016

Cited by 103 publications

(84 citation statements)

References 1 publication

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“…[7] The advantages and disadvantages of keeping good or poor clinical records, respectively, are summarized in [ Table 4]. [8] Clinical records has medical and legal relevance and therefore it must be complete, legible and of the highest quality [ Figure 2]. Our public teaching hospital still maintaining hand written patient's identification and clinical entry in predesigned space filling style case note booklet.…”

Section: Discussionmentioning

confidence: 99%

Clinical Record Keeping Survey of Patients Admitted to Misurata Central Hospital

Alfoghi¹,

Ramadan²

2017

Ann. Int. Med. Den. Res.

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Background: The current survey are to evaluate the quality of patient identification documentation and medical notes writing in our public hospital and to ensure compliance with the international clinical record keeping requirements. Methods: This is a retrospective cross-sectional survey of randomly collected case notes from the hospital documentation and information office, where 100 case notes for patients who were admitted during 2015, from five hospital wards and a total of 500 case notes were reviewed and its completeness was assessed in the contents of hospital medical files as frequencies (%). Results: The patient's registration number, Unit, Name, Age, Nationality, Admission and Discharge dates were recorded in (85-100%) of cases in almost all wards. Mother's name, Birth date, Marital status, Profession, Place of work, Phone number in General Medicine, General Surgery and Orthopaedic wards were recorded in (<20% of cases). Address, Final diagnosis, Outcome also were recorded in (<50%) in General Medicine wards, and in (80-100%) in Surgery and Orthopaedic wards. All the late parameters were recorded in (92-100%) in Obstetric ward. Regarding pediatric wards, the same data were recorded in (60-85%) for all parameters. Regarding Time, round's leader, doctor's name and Signature on the clinical entry notes were all recorded in (<40%), doctor's Designation was not written at all. Conclusion: This survey shows the documentation of important patient information is lacking behind the international standards. Poor documentation in medical records might compromises the quality of care, had a medico-legal implications and undermine analyses based on retrospective medical files reviews.

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Section: Discussionmentioning

confidence: 99%

Clinical Record Keeping Survey of Patients Admitted to Misurata Central Hospital

Alfoghi¹,

Ramadan²

2017

Ann. Int. Med. Den. Res.

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“…It provides information that will be used for planning, the continuous care of patients, it creates a medium of communication among health professionals, for research, quality assurance and medico legal defense [1,2]. The anaesthetic record is a key element of good anaesthetic practice.…”

Section: Discussionmentioning

confidence: 99%

“…Clinical record keeping is a crucial part in good professional practice and the delivery of quality healthcare [1]. Moreover, good clinical record keeping enhances the continuity of care and communication among different healthcare professionals [1].…”

Section: Introductionmentioning

confidence: 99%

“…Moreover, good clinical record keeping enhances the continuity of care and communication among different healthcare professionals [1]. According to the 2009 World Health Organisation (WHO) guidelines for safe surgery, documents and documentation for effective communication and the exchange of information in the operating room are pivotal [2].…”

Section: Introductionmentioning

confidence: 99%

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Audit on Anaesthetic Record Completeness at A University Teaching Hospital Operation Theater of Low -Resource Setting, 2013

2017

JACCOA

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Background: Anaesthetic record is an essential part of the patient's medical record. It includes the perioperative management that is relevant to the anaesthesia practice. This information helps other staff who will be involved in the care of the patient, for medico-legal defense and for quality assurance. We sometimes found anaesthetic recording sheets with incomplete information during the postoperative visit of patients in the recovery room and on the wards in our hospital. We aimed to assess the level of anaesthetic record completeness. Methods:A cross-sectional study was conducted from February 18-March 18, 2013. All patients who were operated under anesthesia during the study period were included. A checklist developed based on our hospital anaesthetic sheet that used for data collection.Result: Hundred and twenty anaesthetic record sheets were audited. The name and time written consistently in local time were documented for all patients. The level of documentation was >90% for age, sex, date of operation, type of operation, medical history, physical examination, allergic history, medication history, consent, induction drugs with their dose, and maintenance drugs. However, the level of record completeness was < 50% for the content of consent, pre-induction vital signs, intraoperative vital signs, start and end of both anesthesia and surgery, type of regional anaesthesia, intraoperative blood loss, and order for postoperative management. Conclusion and recommendation:The level of anaesthetic record completeness was substandard in our hospital compared with the recommendations of WFSA and AAGBI. Training should be given for anaesthetists about the relevance of appropriate documentation for perioperative patient care. Furthermore, We suggest that clinical audit need to be carried out regularly in this hospital until the anaesthetist meet the standards, and in other similar settings in the country to know the magnitude of the problem and to establish strategies that may improve the practice of clinical record keeping.

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“…Establishing and documenting information about an individual's response to therapeutic agents is a core component of Good Medical Practice and record keeping . In particular, documentation of any adverse responses, either due to known extension of the pharmacological action of the drug, or unexpected, unpredictable reactions that may be genetically determined or immunologically mediated, is key to ensuring avoiding inappropriate re‐exposure, ensuring patient safety and optimising continuing care.…”

Section: Introductionmentioning

confidence: 99%

Sustaining and spreading penicillin allergy delabelling: A narrative review of the challenges for service delivery and patient safety

Jani¹,

Williams

Krishna

2020

Brit J Clinical Pharma

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Many patients report allergies to penicillin, although in over 90% of these the label of penicillin allergy is shown to be incorrect following comprehensive testing. Inappropriate and inaccurate penicillin allergy labelling is a barrier to antimicrobial stewardship and can lead to patient harm. This review assesses an emergent evidence base and trend favouring delabelling using direct oral penicillin challenges following a stratified risk assessment of the likelihood and existence of true penicillin allergy, to identify and make recommendations for key components for implementation in standard practice. Research to date has focussed on the feasibility and clinical and financial outcomes of these direct delabelling strategies. There is a paucity of studies exploring the views and engagement of patients and healthcare professionals, and a gap in the evidence for prerequisites to safely deliver, sustain and spread the implementation of such services across health systems.

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How to keep good clinical records

Cited by 103 publications

References 1 publication

Clinical Record Keeping Survey of Patients Admitted to Misurata Central Hospital

Clinical Record Keeping Survey of Patients Admitted to Misurata Central Hospital

Audit on Anaesthetic Record Completeness at A University Teaching Hospital Operation Theater of Low -Resource Setting, 2013

Sustaining and spreading penicillin allergy delabelling: A narrative review of the challenges for service delivery and patient safety

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