Year: 2024
Type: article
Abstract: BACKGROUND: Admission notes are an important aspect of clinical practice and a vital means of communication among healthcare professionals. Incomplete or poor clinical documentation on admission can lead to delayed surgery. PATIENTS AND METHODS: A retrospective analysis of 20 consecutive admission notes to our department was compared against the Royal College of Surgeons standards (GSP 2014). A new admission proforma was designed, and after the introductory period, two further retrospective cycles were performed. RESULTS: In total, 60 admission notes were analysed. Following the introduction of the proforma, there was an overall improvement in the documentation of the quality and quantity of notes studied. CONCLUSION: Our study demonstrated that a well-structured admission protocol can improve the overall quality of admission notes.
Source: BMJ Open Quality
Authors: Munzir Akasha, Oliver Boughton, May Cleary
Institutions: University Hospital Waterford, University College Cork
Language: English
Subfield: Health Information Management
Field: Health Professions
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $1,839
OpenAlex ID: W4402693294