Electronic records legible and attributable – the way forward for OMFS
22 June 2018
Are we documenting inpatient records as well as we should, Daniel Armstrong asked at his presentation to the BAOMS Annual Scientific Meeting in Durham?
The audit of 100 cases he conducted at the Queen Victoria Hospital in East Grinstead alarmingly found that 96% of patients did not have handover outcomes recorded in inpatient records: “Furthermore, 12% of patients had no consultant presence documented, and only 22% of records reflected clear active patient involvement with surgical decision-making,” he said.
The audit revealed that most clinical records were dated and signed, but 82% of patients had at least one clinical record that was not timed, and 75% had at least one illegible record.
The result of these findings led Daniel Armstrong to develop an electronic form that would be both “legible and attributable”, he explained.
The electronic form is used exclusively in OMFS, but the aim is to roll it out to plastics too: “This will provide efficiency, better standardisation and clearly demonstrate departmental conformity to national standards.”
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