Improving the Quality of Clinical Notes Plymouth Healthcare NHS Trust Catherine Bell, Joseph Clarke, Kyle Flegg, Matt Hi

1. Improving the Quality of Clinical Notes Plymouth Healthcare NHS Trust Catherine Bell, Joseph Clarke, Kyle Flegg, Matt Hill, Lauren Robbins and Kerri Tucker • Introduction • Good clinical records are crucial to patient care and safety. A consultation on the surgical ward round should take approximately ten minutes. However, the surgical ward-round does not often afford this amount of time per patient leading to a poor standard of documentation, which often does not reflect the doctor-patient consultation and may have medico-legal implications1. • The Royal College of Physicians sets out generic medical record keeping standards which state that every page in the medical record should include2: • patient’s name, identification number and location in the hospital. • continuum of patient care in chronological order. • date, time and signature. • most senior healthcare professional present (responsible for decision making at the time the entry is made). • Methodology • We initially collected baseline data incorporating several key criteria - such as time taken to find the set of notes, time taken to locate the latest entry in the notes, presence of patient identifying details and responsible consultant, date and time of notation and chronology of notations – against which we could measure improvement. • In the 1st PDSA cycle we added a ‘surgical bookmark’ to help reduce the time wasted in finding the latest entry in the notes. • In the 2nd PDSA cycle we asked the ward-clerk to insert patient identifying labels to blank continuation sheets on admission to the ward. Results Figure 1 and 2 show that after PDSA Cycle 1 there was an improvement in both the number of recurrent notes that contain a ‘surgical bookmark’ and the time taken to locate the patient notes, though these improvement were not fully sustained throughout PDSA cycle 2 perhaps due to the effect of the preceding bank holiday. Figure 3 shows improvement in number of consecutive notes with patients details missing after PDSA Cycle 2. Conclusion This Improvement Project identifies poor compliance with standards of documentation. We demonstrates that a ‘surgical bookmark’ reduces time wasted in locating the correct page for documentation. We also demonstrate an implementation to improve compliance with record keeping standards that have medico-legal implications. References 1 Fernando KJ, Siriwardena AK. Standard of documentation of the surgeon-patient consultation: current surgical practice. Br J Surg 2001; 88: 309-12. 2 Carpenter I, Bridgelal Ram M, Croft GP, Williams JG. Medical records and record-keeping standards. Clin Med 2007; 7: 328-31.