BACKGROUND: Accurate record keeping can enhance patient care by promoting continuity and consistency of management, and aid evaluation of clinical practice. To improve paediatric asthma management, the paediatric respiratory team in a large district general hospital developed a pre-printed asthma review sheet (pro forma) for use at asthma follow-up clinics in the paediatric outpatient department. To assess the pro forma's effectiveness, the team examined the quality of clinical documentation during a retrospective audit of entries in the case notes of 100 patients, and compared it with that in 100 completed pro formas. The completed pro formas contained information on general progress, symptom severity and management of the child since the last medical review. CONCLUSION: The pro forma was shown to improve overall documentation. It not only aided the collection of relevant, clinically useful information, thereby helping clinicians to make decisions on management regimens, but it, also proved to be a valuable assessment tool for the management of chronic asthma in children.
BACKGROUND: Accurate record keeping can enhance patient care by promoting continuity and consistency of management, and aid evaluation of clinical practice. To improve paediatric asthma management, the paediatric respiratory team in a large district general hospital developed a pre-printed asthma review sheet (pro forma) for use at asthma follow-up clinics in the paediatric outpatient department. To assess the pro forma's effectiveness, the team examined the quality of clinical documentation during a retrospective audit of entries in the case notes of 100 patients, and compared it with that in 100 completed pro formas. The completed pro formas contained information on general progress, symptom severity and management of the child since the last medical review. CONCLUSION: The pro forma was shown to improve overall documentation. It not only aided the collection of relevant, clinically useful information, thereby helping clinicians to make decisions on management regimens, but it, also proved to be a valuable assessment tool for the management of chronic asthma in children.
Authors: Sarah E M Lobo; James Rucker; Madeleine Kerr; Fidel Gallo; Giles Constable; Matthew Hotopf; Robert Stewart; Matthew Broadbent; Martin Baggaley; Simon Lovestone; Peter McGuffin; Myanthi Amarasinghe; Stuart Newman; Gunter Schumann; Philip J Brittain Journal: Int J Med Inform Date: 2015-05-19 Impact factor: 4.046