Lava Chalikonda1, Nigel Phelan2, John O'Byrne2. 1. Cappagh National Orthopaedic Hospital, Dublin, Ireland. lavac@doctors.org.uk. 2. Royal College of Surgeons Ireland, Dublin, Ireland.
Abstract
BACKGROUND: Litigation claims related to surgery have increased significantly in recent years. Despite the medico-legal importance of clinical records, there have been few published studies describing the quality of medical records in orthopaedic surgery. This study aimed to evaluate the quality of clinical note taking in an elective orthopaedic setting over a 10-year period by comparing medical records from 2003 and 2013. METHODS: We used the previously validated Surgical Tool for Auditing Records (STAR) on a sample of 20 medical records from each year. We performed statistical analysis to determine if significant differences existed between 2003 and 2013. RESULTS: There was an overall improvement in the quality of medical records from 76.7% (range 68-82%) in 2003, to 81% (range 72-88%) in 2013 (P value < 0.05). There were significant improvements in the subsequent entry score, from 5.15 to 6.3 (P value < 0.05) and discharge summary score, 6.65 to 7.95 (P value < 0.05). The score for the operative record section decreased from 8.45 to 8.0 (P value < 0.05). CONCLUSION: The overall standard of medical records in both 2003 and 2013 was high and comparable to other surgical specialties. There was no possible correlation observed between standards of medical records and increasing litigation claims in surgery. Widespread implementation of Electronic Medical Records (EMRs) is likely to have a significant impact on the quality of medical records. Further research is required to determine how the design of EMRs influences how healthcare professionals record data.
BACKGROUND: Litigation claims related to surgery have increased significantly in recent years. Despite the medico-legal importance of clinical records, there have been few published studies describing the quality of medical records in orthopaedic surgery. This study aimed to evaluate the quality of clinical note taking in an elective orthopaedic setting over a 10-year period by comparing medical records from 2003 and 2013. METHODS: We used the previously validated Surgical Tool for Auditing Records (STAR) on a sample of 20 medical records from each year. We performed statistical analysis to determine if significant differences existed between 2003 and 2013. RESULTS: There was an overall improvement in the quality of medical records from 76.7% (range 68-82%) in 2003, to 81% (range 72-88%) in 2013 (P value < 0.05). There were significant improvements in the subsequent entry score, from 5.15 to 6.3 (P value < 0.05) and discharge summary score, 6.65 to 7.95 (P value < 0.05). The score for the operative record section decreased from 8.45 to 8.0 (P value < 0.05). CONCLUSION: The overall standard of medical records in both 2003 and 2013 was high and comparable to other surgical specialties. There was no possible correlation observed between standards of medical records and increasing litigation claims in surgery. Widespread implementation of Electronic Medical Records (EMRs) is likely to have a significant impact on the quality of medical records. Further research is required to determine how the design of EMRs influences how healthcare professionals record data.
Entities:
Keywords:
Electronic medical records; Medical note taking; STAR score
Authors: Jennifer S Love; Adam Wright; Steven R Simon; Chelsea A Jenter; Christine S Soran; Lynn A Volk; David W Bates; Eric G Poon Journal: J Am Med Inform Assoc Date: 2011-12-23 Impact factor: 4.497
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