Clinical audit on documentation of medical records at a teaching hospital in London, United Kingdom

Objective To compare current practice in paediatric units of St. George's Hospital, London, with the Clinical Negligence Scheme for Trusts (CNST) guidelines and service standards for documentation of medical records and identify desirable changes.

Method Fifty Bed Head Tickets (BHTs) from 2 paediatric medical units at St. George's Hospital, London were audited using a questionnaire. Proforma used on admission and daily records were audited.

Results In admission proforma, recording of parents' ages was 24%. In history section, birth history and developmental milestones were noted in 74% of records. In examination section, the most poorly filled parts were ‘endocrine' at 6% and ‘skeletal system' at 38%. Differential diagnosis and treatment plan were complete in 90% of notes. All entries by doctors and nurses were legibly written and signing and dating of entries had been done in over 80% while writing time of entry and printing of name had been done only in 40% and 38% respectively. A daily entry by a doctor was noted in 98% of BHTs. A consultant had reviewed 56% of the children who had been in-ward.  

Key words: clinical audit, documentation of medical records, teaching hospital, United Kingdom

DOI = 10.4038/sljch.v36i1.41

Sri Lanka Journal of Child Health, 2007; 36: 14-15