Charting Errors in a Teaching Hospital

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Abstract

Objective

The objective of this study was to assess charting errors by junior trainees in the emergency department at the beginning of the academic year and to evaluate the effect of audits and reminders in reducing charting errors in July.

Methods

Medical records from June and July 2006 were reviewed to identify incomplete documentations (charting errors) in 5 areas. The audit was repeated in July 2007 after sample charts were displayed, and reminders were sent.

Results

There were 129 patient records completed by 12 trainees in June 2006 and 122 by 11 trainees in July 2006. The mean charting error rate for July (24%) was significantly higher than that in June (17%) (P = 0.0041). The mean charting error rate reduced to 14% after the intervention in July 2007.

Conclusions

There is a significant increase in charting errors by new trainees in July compared with June. A simple intervention of reminders and alerts significantly reduced charting errors in July.

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