Audit of the quality of documentation in an eye casualty department

Abstract

Purpose

The purpose of this paper was to prospectively audit an eye department's quality of note keeping in a casualty setting.

Design/methodology/approach

The paper found that locally agreed standards for quality of documentation were based on criteria integral to the patient pathway. Assessment of local practice, was carried out, by reviewing patient records. The results were compared against locally agreed standards and indicators were divided into those, which the unit performed well, and those, which could be improved, necessitating action. Changes in practice, including education and document redesign, were carried out. The results were re‐audited and compared with previous cycles.

Findings

The paper found that 145 records were audited in four cycles over a nine‐month period. The department performed consistently well in the majority of indicators. All but one of the poorly performing indicators improved with the changes in practice. These improvements were sustained with repeated re‐audit.

Originality/value

The paper shows that good note keeping in the unpredictable setting of the casualty clinic is difficult, which impacts on patient care. This simple audit has had a beneficial effect on the unit's standard of note keeping in the casualty environment and can easily be adapted to improve documentation in other clinical specialties and scenarios.

Citation

Liyanage, S.E., Thyagarajan, S., Khemka, S., Blades, M. and de Alwis, D.V. (2006), "Audit of the quality of documentation in an eye casualty department", Clinical Governance: An International Journal, Vol. 11 No. 3, pp. 187-192. https://doi.org/10.1108/14777270610683119