title: A study on the standard of documentation of lumbar puncture in neurology department of a major Irish Teaching Hospital in Ireland.
abstract: OBJECTIVE
  Poor documentation following lumbar puncture (LP) had always been a matter of concern. This study aimed to investigate the documentation pattern of neurology house officers, registrars (Regs), and specialist Regs following LP in a major teaching hospital.
  
  
  METHODS
  Total hundred patient records were examined in the light of a carefully designed proforma containing 15 important indicators of good-quality LP documentation.
  
  
  RESULTS
  Mean number of indicators overall documented by doctors was found to be 6.24 ± 3.0037. The mean number of indicators recorded by house officers was 5.11 ± 3.01 and Regs was 7.56 ± 3.28. A total of 33% LPs were performed without a documented consent. Only 36% performers documented the type and size of needle they used during the procedure. Only 46% documents revealed the strength and name of the local anesthetic used. Statistically significant difference between senior house officers and Regs in terms of numbers of indicators documented was noted.
  
  
  CONCLUSIONS
  The documentation standard among neurology junior doctors remained poor.
authors: Department of Neurology, Mater University Hospital, Dublin, Ireland.
authors: Shakya
authors: S
authors: Bhattacharjee
authors: Gurpreet
authors: G
authors: Kaur
keywords: Consent; documentation; knowledge; lumbar; neurology; puncture