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

2. 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 devised by 3 surgeons

3. 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

4. GMC – Good Medical Practice

5. CRABEL SCORE

6. 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

7. 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 st January 2016
Initial audit cycle used the RCS proforma, second cycle and third cycle used a modified RCS proforma.

8. RCS proforma
Initially this proforma
First Cycle
Second cycle

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

10. 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

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

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

13. 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%)

14. 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%)

15. 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

16. 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

17. 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