Academic journal article Australian Health Review

Medical Record Keeping and System Performance in Orthopaedic Trauma Patients

Academic journal article Australian Health Review

Medical Record Keeping and System Performance in Orthopaedic Trauma Patients

Article excerpt

Introduction

Medical records remain an essential tool in modern medical practice, whether in hand-written or electronic form. They are the key to healthcare professional communication regarding ongoing patient management, often serving as the sole point of communication between multidisciplinary teams, in both the in-patient and out-patient settings. They also act as an aidemémoire for the treating practitioner to ensure continuity and that non-contradictory advice is provided to the patient. Furthermore, in an increasingly litigious society, medical records are an essential medicolegal document, and accurate documentation is vital in cases of accused negligence and patient complications.1,2 Despite the importance of comprehensive documentation in the medical record, numerous examples of poor documentation have been demonstrated,3-7 including substandard documentation during consultant ward rounds by junior doctors leading to a breakdown in healthcare professional communication and potential patient mismanagement.3,4 Further inadequacies of medical record documentation have been demonstrated in surgical discharge notes, with complete and correct documentation reported to be as low as 65%.5

Among orthopaedic populations, poor standards of documentation have been demonstrated previously.6,7 One such study found that no documentation of neurovascular status in orthopaedic patients with extremity trauma was complete for motor, sensory and vascular components.6 Further, Cascio et al. demonstrated documentation of progress notes for 70% of patients with compartment syndrome were inadequate despite the potential for negative patient outcomes and a significant risk of medicolegal action.7

Although prior evidence suggests poor medical record documentation in surgical and orthopaedic units, there is a need to identify key areas of weakness in all aspects of documentation, because feeding back to the medical staff in terms of these deficiencies can lead to improvement in performance.8

The aim of the present study was to evaluate important aspects of the orthopaedic medical record, including the operative report, discharge summary and out-patient progress notes, and to determine whether any deficiencies in documentation exist in these areas. The areas reviewed were considered to be critical to patient care and to have potential for creating an adverse outcome when incorrect instructions were pursued. The timing of postoperative instructions and the experience of the person undertaking the review can also play an important role in patient management. Hence, the present study evaluated the timing of appointments and the seniority status of the medical practitioner at the out-patient attendance.

Methods

Ethics approval was obtained through the Alfred Health Human Ethics Committee.

Medical records were reviewed retrospectively for patients attending an outpatient clinic in May and June 2014 at a Level 1 trauma centre. These records had documentation from the patient's acute hospital stay in 2013 and 2014. Daily out-patient clinic lists were analysed for patients with acute traumatic lower limb injuries, either unilateral or bilateral, treated surgically by the orthopaedic unit. The number and type of injuries were defined using International Classifications of Diseases (ICD)10 codes.9

Medical records were accessed electronically. Records were analysed for documentation of aspects of management relevant to the ongoing care of the patient. Areas of the orthopaedic medical record evaluated were the operative report, discharge summary and the first and second out-patient review progress notes (Table 1).

A senior orthopaedic surgeon and senior orthopaedic physiotherapist agreed on the elements of the record critical to ongoing patient management and developed evaluation sheets.

Results

Two hundred orthopaedic patient medical records were evaluated. The patient population had a mean age of 42. …

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