International Journal of Collaborative Research on Internal Medicine & Public Health
Vol. 4 No. 5 (2012)
538
Results
18 sets of medical notes were reviewed with the target = 100%
Other information was also collected using the proforma (e.g. DNR status and mistakes in the
notes) however this was of no comparative use as only one in every 10 notes had information
worth collecting so has been omitted from the results tables. 35 filled in questionnaires were
returned from the target group. The results from each question are discussed below. After
conducting the first cycle over 90% of entries audited had the date, patient name and hospital
number present. The major issue was writing the time after each entry, as only an average of
67% of case notes reviewed possessed this. 85% of the sample had a legible printed name and
82% a signature according to data after the first audit cycle collection. Analysis of cycle 2
showed there was an obvious improvement as all the parameters being measured increased in
incidence. Over 95% now had a patient name and hospital number on every page, with over 94%
of all entries having the date recorded. Over 86% had a legible printed name and signature,
which indicated an obvious improvement from the previous week. The biggest progression was
seen in recording the time on written notes, which rose by 9%. Cycle 3 also showed an
improvement with 3 parameters reaching the desired target of 100% - writing the date, patient
name and patient hospital number. 96% of entries displayed a signature and legible printed name
and 83% of entries had the time present. Over the course of the 3 weeks of the audit, the sample
reviewed showed an average increase of 16% of entries having the time written. Similarly
incidences of a legible printed name on entries rose by 14% and having a signature present also
rose by 11%. The other parameters all augmented to reach the target level of 100%.
Analysing the data provided by the questionnaire gives information about FGH as a whole site.
This holistic approach provides a more useful analysis tool than limiting the questionnaire to the
professionals whose practices were audited. Out of a sample of 35 participants 60% of the cohort
expressed they were dissatisfied about the current condition of medical notes on their respective
wards. 31% of which were not satisfied with the legibility and organisation of the notes, 25%
with the information available in the notes and 8% dissatisfied with mistakes present. One
participant stated, ‘episodes are written in a random order and this is frustrating.’ Interestingly
60% of the sample had not read any guidelines on medical record keeping (60% were also
dissatisfied with the notes). This question was purposely left with an ambiguity by not stating
specific guidelines i.e. Pennine Acute Medical Trust or RCP guidelines, to apply to more
participants. There may be a correlation between the proportion of people who were dissatisfied
with the notes and those who had not read any guidelines. When asked about the top 3 reasons
for ‘good’ medical record keeping, patient/clinician safety came in as the most important, with
patient care and communication as the 2
nd
and 3
rd
most important reasons respectively. Habit
(45%) was the mode response when asked about non-adherence to guidelines. 42% of the sample
thought it was due to time restraints and 11% believed it was due to lack of training. One
participant added it was due to examples being set by others and remarked that ‘the guidelines
are not appropriate.’ When enquiring about introducing an electronic medical record system
(EMR) 66% of the sample were in favour amidst the rest opposing with concerns about cost,
training and the time it may take to get the system running.