Prospective audit of the quality of ENT emergency clinic notes before and after introduction of a computerized template.
This study evaluated the accuracy of notes in an ENT urgent referral clinic, based on a standard of note keeping established within the trust. The results initially failed to meet the set standard and a change of practice was initiated by introduction of a computerized template that allowed for easier and more accurate data entry. After re-evaluation, the notes were found to be accurate and to contain relevant demographic data in more than 90 per cent of cases.
Hobson
Jonathan C
JC
Department of Otorhinolaryngology-Head and Neck Surgery, Northwick Park Hosptal, Harrow, Middlesex, UK. jchobson@doctors.org.uk
Khemani
Sameer
S
Singh
Arvind
A
D004630:Emergencies; D004739:England; D006236:Handwriting; D006302:Health Services Research; D006801:Humans; D008485:Medical Audit / Q000379:methods; D008499:Medical Records / Q000592:standards; D016347:Medical Records Systems, Computerized / Q000592:standards*; D010036:Otolaryngology / Q000458:organization & administration / Q000592:standards*; D010044:Outpatient Clinics, Hospital / Q000458:organization & administration / Q000592:standards*; D011446:Prospective Studies