| Literature DB >> 3630845 |
Abstract
A form developed to audit the case notes of general medical patients was modified for use in geriatric medicine. The case notes of 41 admissions to the geriatric wards of a teaching hospital were audited with the new form and their contents did not come up to the standard set. Deficiencies were found in those parts of the notes considered to reflect the distinctive features of the specialty, e.g. the functional history, the assessment of mobility and the recording of multidisciplinary case conferences. The introduction of a standard history and examination form to meet the needs of patients admitted to geriatric wards, better training in geriatric medicine for junior doctors and closer scrutiny of medical records by consultants are suggested as ways of improving documentation in the case notes.Entities:
Mesh:
Year: 1987 PMID: 3630845 DOI: 10.1093/ageing/16.4.225
Source DB: PubMed Journal: Age Ageing ISSN: 0002-0729 Impact factor: 10.668