Evidence base: Poor quality record keeping by health care professionals has been repeatedly criticised. Indeed, it is often said legally ‘if something is not documented, then it did not happen.’ We aimed to improve our documentation by creating a new admission proforma with prompts to further assessment in key areas in keeping with the standards set by the Royal College of Physicians and NHS Scotland.
Change strategies: In May 2012 admission documentation was assessed in thirty case notes from a geriatric medicine assessment ward in Gartnavel Hospital. A new proforma was subsequently created based on the first loop of audit and consultation with the senior medical staff. The documentation was re-audited in a further thirty cases during April 2013 using the same data collection tool.
Change effects: Introduction of the new proforma improved documentation within a number of areas. Medicines reconciliation accuracy improved from 43% to 67%, with prompts improving subsequent senior review of medications from 13% to 70%. Cognitive assessment increased from 73% to 93% with a delirium prompt improving recognition from 40% to 62.5%. Assessment of capacity increased from 23% to 77%, whilst documentation of DNACPR decisions in appropriate patients also rose from 16% to 66%.
Our new document also prompts assessment in other areas including continence and anticoagulation of patients with atrial fibrillation, although these have not been analysed in this audit.
Conclusion: We have demonstrated an improvement in the quality of our record keeping by enhancing the content and structure of our admission proforma. The use of specific prompts has also improved assessment of key areas relevant to the care of older adults.