Using a template in fracture clinic leads to a sustained improvement in clinical notes.
Changes in shift work patterns have meant that patients presenting to a hospital fracture clinic for follow-up may see a different doctor on each visit. Clear clinical notes are essential in this setting, for both clinical and medico-legal reasons. We tried to improve documentation in the fracture clinic by using an education intervention followed by the introduction of a fracture clinic template. Audits were performed at baseline in January 2002, then in July 2002 after the education intervention, in October 2002 after the template introduction, and finally in March 2005. The combined approach of education and involving staff in design of the template followed by introduction of the template, resulted in a significant and sustained improvement in fracture clinic documentation.
Yates
Kim M
KM
Emergency Medicine Research, Emergency Care Centre, North Shore Hospital, Private Bag 93 503, Takapuna, Auckland, New Zealand. Kim.Yates@WaitemataDHB.govt.nz
D004282:Documentation / Q000592:standards*; D005260:Female; D050723:Fractures, Bone / Q000628:therapy*; D006801:Humans; D008297:Male; D008485:Medical Audit; D008499:Medical Records / Q000592:standards*; D009520:New Zealand; D009985:Orthopedics / Q000592:standards; D010044:Outpatient Clinics, Hospital / Q000458:organization & administration / Q000592:standards*; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000592:standards; D015397:Program Evaluation