Introduction Accuracy and consistency in clinical note-keeping is an essential element of clinical governance. In this busy GUM clinic, up to 12 different healthcare practitioners (both nurses and doctors) see patients for their history and examination, as well as taking tests, making microscopic diagnoses, giving treatment and notifying contacts. With this many staff of differing clinical backgrounds seeing patients autonomously, it is important that minimum standards of documentation are maintained. This study reports the use of an audit tool designed to provide clinic workers with regular feedback on their individual record-keeping performance compared to the clinic as a whole, thereby identifying areas where documentation standards can be improved.
Methods The audit was started in January 2009 and carried out monthly for 12 months with three sets of clinical notes audited per clinician each month. Collective scores for the clinic were issued on a monthly basis, with individual clinicians also receiving their own scores confidentially every quarter. The audit was discontinued for a year, then repeated so as to evaluate the extent to which improvements made in the first year had been maintained. Clinicians were unaware that the re-audit was taking place. The audit was based on 31 separate criteria divided into administrative (7 criteria), clinical (20 criteria) and health adviser (4 criteria) sections. This report focuses on the outcome of the clinical section, which included criteria such as adequacy of history and examination records, choice of tests conducted, consistency of diagnoses with findings, and suitablility of treatments prescribed. The internal standard was set at 100% for each criterion.
Results Overall scores for individual clinicians in the first month ranged from 72% to 96%, with median 82% and mean 83%. At month 12, the range was 87–100%, median 98%, mean 97%. The repeat audit conducted after a 12-month lapse revealed overall scores ranging from 89 to 100%, median 98%, mean 97%.
Conclusions This study shows that it is possible to substantially improve standards of clinical record-keeping in a GUM clinic staffed by clinicians from a variety of backgrounds, through the intensive application of a wide-ranging audit tool and the use of individual feedback. The repeat audit conducted a year after the 12-month intensive phase shows that these improvements appear to be both sustainable and durable.