title: Clinical record keeping in patients receiving antibiotics in hospital.
abstract: BACKGROUND
  Antibiotic prescribing is associated with the growth of antibiotic resistance in micro-organisms. Prescribing therefore needs to be restricted by well-designed antibiotic protocols. Audit of such protocols is only possible if clinical information about infection is properly recorded.
  
  
  OBJECTIVE
  To assess the quality of clinical data recording in case notes of patients receiving antibiotics in hospital and to assess the effect of feedback of this information on clinical practice.
  
  
  METHODS
  Four point prevalence surveys.
  
  
  METHODS
  Directorate of General Medicine, Dundee Teaching Hospitals NHS Trust.
  
  
  METHODS
  Inpatients receiving antibiotics.
  
  
  METHODS
  Feedback of results from the first two surveys to clinicians.
  
  
  METHODS
  Proportion of patients in the Medical Directorate with the recording of an antibiotic indication and the temperature in the case notes before, immediately after, and three months after, feedback of survey results.
  
  
  RESULTS
  In each survey one third of patients were receiving antibiotics. The antibiotic indication was recorded in 64% of patients prior to feedback and in 86.5% after feedback (p = 0.004). Three months later this had fallen to 74%. Temperature recording improved between 2nd and 3rd surveys (57% to 86.1%, p < 0.001) and declined to 61% in the 4th survey (p < 0.001). Respiratory infection was the commonest recorded indication for an antibiotic; recording of this indication improved between the 2nd and 3rd surveys but declined by the 4th survey.
  
  
  CONCLUSIONS
  Audit and feedback of information about clinical record keeping improves standards but improvements are not sustained. Clinical record keeping must be improved so compliance with antibiotic protocols can be properly audited. An "antibiotic sticker" in addition to immediate concurrent feedback may improve such deficiencies.
authors.affiliation: Infection and Immunodeficiency Unit, Dundee Teaching Hospitals NHS Trust, King's Cross Hospital, Dundee DD3 SEA.
authors.forename: R A
authors.initials: RA
authors.lastname: Seaton
authors.forename: D
authors.initials: D
authors.lastname: Nathwani
authors.forename: G
authors.initials: G
authors.lastname: Phillips
authors.forename: R
authors.initials: R
authors.lastname: Millar
authors.forename: P
authors.initials: P
authors.lastname: Davey
mesh_terms: D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D004282:Documentation; D017723:Drug Utilization Review; D019983:Guideline Adherence; D019538:Health Care Surveys; D006779:Hospitals, Public / Q000592:standards*; D006784:Hospitals, Teaching / Q000592:standards*; D006801:Humans; D008499:Medical Records / Q000592:standards*; D017410:Practice Guidelines as Topic; D012606:Scotland
chemical_list: D000900:Anti-Bacterial Agents