title: Data recording aids in acute admissions.
abstract: OBJECTIVE
  Clinical data capture and transfer are becoming more important as hospital practices change. Medical record pro-formas are widely used but their efficacy in acute settings is unclear. This paper aims to assess whether pro-forma and aide-memoire recording aids influence data collection in acute medical and surgical admission records completed by junior doctors.
  
  
  METHODS
  During October 2007 to January 2008, 150 medical and 150 surgical admission records were randomly selected. Each was analysed using Royal College of Physicians guidelines. Surgical record deficiencies were highlighted in an aide-memoire printed on all A4 admission sheets. One year later, the exercise was repeated for 199 admissions.
  
  
  RESULTS
  Initial assessment demonstrated similar data capture rates, 77.4 per cent and 75.9 per cent for medicine and surgery respectively (Z = -0.74, p = 0.458). Following the aide-memoire's introduction, surgical information recording improved relatively, 70.5 per cent and 73.9 per cent respectively (Z = 2.01, p = 0.045). One from 11 aide-memoire categories was associated with improvement following clinical training. There was an overall fall in admission record quality during 2008-9 vs 2007-8.
  
  
  CONCLUSIONS
  The study compared performance among two groups of doctors working simultaneously in separate wards, representing four months' activity.
  
  
  CONCLUSIONS
  Hospital managers and clinicians should be mindful that innovations successful in elective clinical practice might not be transferable to an acute setting.
  
  
  CONCLUSIONS
  This audit shows that in an acute setting, over one-quarter of clinical admission data were not captured and devices aimed at improving data capture had no demonstrable effect. The authors suggest that in current hospital practice, focussed clinical training is more likely to improve patient admission records than employing recording aids.
authors.affiliation: School of Medical Sciences, Bangor University, Bangor, UK. deantwilliams@aol.com
authors.forename: Dean T
authors.initials: DT
authors.lastname: Williams
authors.forename: David
authors.initials: D
authors.lastname: Hoare
authors.forename: Guy
authors.initials: G
authors.lastname: Shingler
authors.forename: Charlie
authors.initials: C
authors.lastname: Fairweather
authors.forename: Christopher
authors.initials: C
authors.lastname: Whitaker
mesh_terms: D000208:Acute Disease / Q000628:therapy; D003625:Data Collection / Q000379:methods*; D006801:Humans; D008487:Medical History Taking; D008499:Medical Records; D010343:Patient Admission; D010355:Patient Identification Systems; D010808:Physical Examination