OBJECTIVE: To evaluate the current status and improvement in quality of surgical records in 2014 as compared to previous audit of 2012 at Dow University Hospital (DUH), Karachi Pakistan.
METHODS: A review of records of all the patients in surgery department of DUH were done according to Modified Adjusted Note Keeping and Legibility (ANKLe) score in first audit. After sharing the results of the first audit and education of the junior doctors, re-audit was done and completed from June 2014 to August 2014. The modified ANKLe score with an overall total-score of 24 consists of the combination of, the content (out of 20) and legibility (out of 4). An acceptable score is at least 20 (content score 17/20; legibility score 3/4). Scores were compared to the previous study conducted in 2012.
RESULTS: Records of 290 patients were assessed. Mean scores for total ANKLe score, content and legibility were 19.94±3.36, 16.48±3.12 & 3.56±0.581 respectively as compared to 18.4±2.1, 14.4±2.1 & 3.9±0.2 respectively in 2012. The benchmark of 80% (20/24 score) for total ANKLe score was achieved in 63.7% compared to 26.1% in 2012. Similarly, standard of >17/20 for contents and >3/4 for legibility was achieved in 60.34% and 95.5% respectively as compared to 6.8% & 99.1% respectively in 2012.
CONCLUSION: Overall, quality of surgical record keeping in DUH has been improved but still not at ideal status. The ANKLe score can be used in hospitals. By giving education and guidance to junior doctors the quality of medical records can be improved.KEY WORDS: Medical Records (MeSH); Documentation (MeSH); Clinical Audit (MeSH); Case notes (Non-MeSH); Quality of Health Care (MeSH); ANKLe score, (Non-MeSH)
Jawaid M, Khalique A, Mossa FA, Bakhtiar N. The quality of surgical case notes using CRABEL score at Dow university hospital. J Postgrad Med Inst 2012; 26(4): 412-7.
Chamisa I, Zulu BM. Setting the records straight--a prospective audit of the quality of case notes in a surgical department. S Afr J Surg. 2007;45:94-5.
N Bakhtiar, A Khalique, FA Moosa, M Jawaid.Are we achieving the bench mark of surgical clinical case notes at Dow University Hospital? Pak J Surg 2012; 28(4): 243-246
Wood DL. Documentation guidelines: evolution, future direction and compliance. Am J Med. 2001; 110(4):332-33.
C Hill. An Audit into Orthopaedic Surgical In-patient Record Keeping – Are We Doing Enough? The IJHCA. 2008;6(2).
Dexter S, Hayashi D, Tysome JR. The ANKLe score: an audit of otolaryngology emergency clinic record keeping. Ann R Coll Surg Engl. 2008;90:231–234.
Royal College of Physicians, London. Generic medical record keeping standards. [cited on January 12, 2017). Available from URL: https://www.rcplondon.ac.uk/projects/outputs/generic-medical-record-keeping-standards
Crawford JR, Beresford TP, Lafferty KL. The CRABEL score – a method for auditing medical records. Ann R Coll Surg Engl. 2001;83:65–68.
Jawaid M, Bakhtiar N, Khalique A, Masood Z. Quality of surgical case notes at Dow University Hospital according to modified ANKLe score. Pak J Med Sci 2013;29(4):1038-1041. doi: http://dx.doi.org/10.12669/pjms.294.3813
Dexter SC, Hayashi D, Tysome JR. The ANKLe Score: An Audit of Otolaryngology Emergency Clinic Record Keeping. Ann R Coll Surg Eng .2008;90(3):231-234. doi:10.1308/003588408X261537.
Crombie I, Davies H, Abraham S, et al. The audit handbook: improving health care through clinical audit. Chichester: John Wiley & Sons, 1993.
Hall R, Balachandren N, Aujla B, Haloob M. Improving admission records: use of clerking proforma for gynaecology patients. [Online] 2012 [cited on 2013 May 10]. Available from URL: http://epostersonline.s3.amazonaws.com/ rcog2011/rcog2011.0300078.NORMAL.pdf
Mann R1, Williams J. Standards in medical record keeping. Clin Med. 2003; 3 :329– 32. doi: 10.7861/clinmedicine.3-4-329
Ghani Y, Thakrar R, Kosuge D, Bates P. ‘Smart’electronic operation notes in surgery: an innovative way to improve patient care. Int J Surgery. 2014 Jan 31;12(1):30-2.
Howard DJ. Structured discharge letter in a department of geriatric medicine. Health Trends. 1986;18:12–4.
Grewal P. Surgical Hospital Audit of Record Keeping (SHARK)—A New Audit Tool for the Improvement in Surgical Record Keeping. Journal of surgical education.2013;70(3):373-6.
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