Perbinder Grewal1. 1. Queen Alexandra Hospital, Portsmouth, UK. perbinder@yahoo.com
Abstract
INTRODUCTION: Accurate and legible record keeping is a crucial part of good medical practice. Surgical Hospital Audit of Record Keeping (SHARK) is a new audit and teaching tool for junior doctors. The author has designed the tool, based on the Royal College of Surgeons guidelines, to anonymously score the different surgical teams' medical records within a hospital. It takes into account regular record keeping during ward rounds, together with the operation note and admission clerking. METHODS: The SHARK audit tool assesses 45 individual areas within surgical records. Fifteen points are apportioned for an initial surgical clerking, 13 for a subsequent record entry, and 17 for the operation note to give an overall score out of 45. It was implemented at 2 hospitals and used to educate medical students. RESULTS: The results were poor and improved with education at both sites. There was 80% total agreement with a κ coefficient for interobserver reliability of 0.6. CONCLUSION: This study shows that the SHARK tool is simple to use, repeatable, and reliable in improving record keeping.
INTRODUCTION: Accurate and legible record keeping is a crucial part of good medical practice. Surgical Hospital Audit of Record Keeping (SHARK) is a new audit and teaching tool for junior doctors. The author has designed the tool, based on the Royal College of Surgeons guidelines, to anonymously score the different surgical teams' medical records within a hospital. It takes into account regular record keeping during ward rounds, together with the operation note and admission clerking. METHODS: The SHARK audit tool assesses 45 individual areas within surgical records. Fifteen points are apportioned for an initial surgical clerking, 13 for a subsequent record entry, and 17 for the operation note to give an overall score out of 45. It was implemented at 2 hospitals and used to educate medical students. RESULTS: The results were poor and improved with education at both sites. There was 80% total agreement with a κ coefficient for interobserver reliability of 0.6. CONCLUSION: This study shows that the SHARK tool is simple to use, repeatable, and reliable in improving record keeping.