title: The TONK score: a tool for assessing quality in trauma and orthopaedic note-keeping.
abstract: BACKGROUND
  Medical case notes are the only lasting interpretation of a patient-physician interaction and are important for good quality patient care. Accurate, legible and contemporaneous note-keeping is important however it can be substandard. This can lead to errors in handover of patients and to medicolegal vulnerability. We present a comprehensive auditing tool for Trauma & Orthopaedics medical case notes and our experience in using it over the last 12 months.
  
  
  METHODS
  The TONK score was developed from a pre-existing system with some additions for Trauma & Orthopaedic case notes, with the incorporation of a legibility scoring system. An initial audit was carried out evaluating the case notes for each team against the TONK score. In order to evaluate the reproducibility of this score, we employed the Cohen's Kappa coefficient and noted substantial agreement. The individual team scores were analysed and the audit cycle completed four months later with the provision of feedback.
  
  
  RESULTS
  Our first audit revealed a mean of 81 with a range from 70 to 90. Subsequent audits over the next two quarters revealed mean scores in excess of 90. Significant improvement has been noted in all areas of documentation and it has been decided to conduct this audit every six months in our department.
  
  
  CONCLUSIONS
  The TONK score is an easy, quick and reproducible tool, which aims to eliminate the weaknesses in Trauma & Orthopaedic medical note-keeping. It emphasises the medicolegal importance of accurate medical note-keeping to doctors at all levels of training.
authors.affiliation: Department of Trauma & Orthopaedics, Rehman Medical Institute Peshawar Pakistan ; Northern Lincolnshire & Goole Hospitals NHS Trust, Scunthorpe General Hospital, Cliff Gardens Scunthorpe DN15 7BH UK.
authors.forename: Zeeshan
authors.initials: Z
authors.lastname: Khan
authors.affiliation: Northern Lincolnshire & Goole Hospitals NHS Trust, Scunthorpe General Hospital, Cliff Gardens Scunthorpe DN15 7BH UK.
authors.forename: Adele E
authors.initials: AE
authors.lastname: Sayers
authors.affiliation: Northern Lincolnshire & Goole Hospitals NHS Trust, Scunthorpe General Hospital, Cliff Gardens Scunthorpe DN15 7BH UK.
authors.forename: Mohammad Usman
authors.initials: MU
authors.lastname: Khattak
authors.affiliation: Northern Lincolnshire & Goole Hospitals NHS Trust, Scunthorpe General Hospital, Cliff Gardens Scunthorpe DN15 7BH UK.
authors.forename: Iain Richard
authors.initials: IR
authors.lastname: Chambers
keywords: Audit; Legibility; Note-keeping; Quality