Surgical Record Keeping Audit-Closing the Audit loop D.Chowdhury, M. Galea, A. Boden, Bhattacharya S.

Introduction Documentation –documents that are supplied as proof of evidence Record keeping- document that preserves information RCS- Guidelines for Clinician on Medical Records and Notes- guidelines produced 1990 and revised 1994 CRABEL Score- protocol published in the RCSEng journal in 2001- devised by 3 surgeons

GMC guidelines Keep clear, accurate and legible records Records to be made at the time of event Record your concerns, including any minor concerns and details of actions taken, information shared relevant to keeping a child or young person safe is available

GMC – Good Medical Practice

CRABEL SCORE

RCS guidelines- 1990 (rev 1994) Covered various sections in details Hospital Record- done at the time of admission Clinical Record Nursing record and care plan Patients undergoing surgery Patients in intensive therapy units Details on discharge Post-Mortem Report Management of Hospital Record

Audit cycles Initial Audit Cycle carried out between April- June 2014 Second audit cycle carried out between 9th June- 19th June 2015 Third audit cycle carried out between 18th November 2015-21st January 2016 Initial audit cycle used the RCS proforma, second cycle and third cycle used a modified RCS proforma.

RCS proforma Initially this proforma First Cycle Second cycle

Methods Audit cycles – prospective patients admitted to the surgical wards 2014 audit- 120 entries 2015 audit- 204 entries 2015-2016 audit- 116 entries All the 3 audit cycles analysed:- Numbers Grade of entry Location

Data Analysis Audit 2014 Re-audit 2015 Re-audit 2015-2016 Station No. of patients 1 14 25 33 2 24 20 16 3 22 40 67

In Numbers... Total no. of entries audited 2014- 120 Average score- 11 Mode-12 Perfect Score of 15- 4

Comparative Analysis Series 1- Audit Cycle 1 Series 2- Re-audit Cycle 2 Series 3- Closing Loop

Analysis In all domains there was improvement between 2nd audit cycle- 3rd cycle apart from the below:- Bleep/GMC- insufficient to use one or the other parameter- was seen as the most poorly performed- (5% vs. 82%) Post- both SHO and SpR carry the 1995 page (50 vs. 71) Observations- (49% vs. 82%) Results- (50% vs. 73%) Time- (60.3% vs. 70%) CHI number (87.9% vs. 91%)

Further Analysis The domains where there was significant improvement were:- Name (90% vs. 75%) Lead clinician (96.5% vs. 75%) Examination findings (71% vs. 67%) Heading (100% vs. 87%) Signature ( 89% vs. 72%)

Discussion- Have we improved? The general documentation may seem to have improved. However:- Results and Clinical Observations is vital The absolute MEWS score is immaterial, however the rate of change is important as well as its breakdown Time, Post and GMC Number is important- medicolegal perspective ‘Make records at the time the events happen, or as soon as possible afterwards’ – Keeping records, Good Medical Practice, GMC Its GMC requirement to include the post of the assessor From nursing perspective and in case of emergency its important to document the level of the assessor

But there is still hope... There has been improvement since the initial audit in 2014 in the following domains:- Name (90% vs. 45%) Legibility (99% vs. 93%) Lead clinician (96% vs. 88%) Heading (100% vs. 72%) Date (100% vs. 98%) These are important domains when taking into consideration with regards to documentation

What should we do ? Be aware of the Good Medical Practice guidance from GMC More widespread use of personal stamp as name, grade and GMC is etched on it Applying good general documentation principles including time and CHI number If the results are written in by the receiving team, comparing results would be easier