FP5.12 - Write what you know: A retrospective documentation audit

Abstract Aims The Royal College of Physicians (RCP) stipulates that every patient entry in the notes should be; dated, timed and signed by the author (name and designation included). Additionally, the content should have a standardised structure and layout with a chronological order to reflect a continuum of patient care. This audit aimed to assess the percentage of patient documentations that were compliant with these standards. Methods We retrospectively evaluated inpatient documentations for general, colorectal and vascular surgery for one week within a district general hospital setting. The data was obtained from electronic documentations. We assessed inpatient documentation for all relevant criteria as per RCP guidelines. Inpatient documentation included; the admission notes, post take ward round, daily ward rounds and inter-speciality discussions. Results A total of 88 patient related entries were reviewed. Of these 89.8% were dated. 42.0% of the entries were timed, with inter-specialty discussion having the highest percentage of recorded times. 93.2% had a standardised structure. The structure of admission entries was the most consistent with standards. 6.8% and 3.4% had the authors designation and signature respectively. Conclusion Clear informative documentation is pivotal for safe and effective patient care. Failure of patient documentation to meet the stipulated standards was established in this audit. Factors including inadequate junior doctor training, pace of ward rounds and reliance on electronic noting systems are potential reasons for poor compliance. Capitalising on opportunities to educate junior doctors is paramount in improving patient care.