title: Safety comes first: are doctors attentive enough to their initial clinical assessment notes?
abstract: Accurate hospital admission/initial history and physical examination [H&P] notes are vital to support patient care. We aimed to assess the quality of H&P notes and to compare medical/surgical, and inpatient/outpatient H&P notes. A cross-sectional study examined 154 initial H&P notes for the adherence to a standard protocol in a tertiary referral hospital. 134 doctors (87.1%) adhered to the correct layout in accordance with the standard. Only 77 doctors (50%) recorded the names of the patient's medications. 106 (68.8%) documented the allergy status. Six doctors (3.9%) omitted an objective record of their own identity. Surgeons were superior at recording admission type (p = 0.0001) and past surgical history (p = 0.002) only. The data in this study show that the standard o completeness of the H&P documentation among doctors is suboptimal. We recommend the introduction of a standardised H&P template to reduce errors.
authors.forename: C
authors.initials: C
authors.lastname: Daly
authors.forename: I
authors.initials: I
authors.lastname: Callanan
authors.forename: M
authors.initials: M
authors.lastname: Butler
mesh_terms: D003430:Cross-Sectional Studies; D004282:Documentation / Q000592:standards*; D006801:Humans; D008487:Medical History Taking / Q000592:standards*; D010808:Physical Examination / Q000592:standards*