| The ANKLe score: an audit of otolaryngology emergency clinic record keeping. | |
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MedLine Citation:
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PMID: 18430339 Owner: NLM Status: MEDLINE |
Abstract/OtherAbstract:
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INTRODUCTION: Accurate and legible medical records are essential to good quality patient care. Guidelines from The Royal College of Surgeons of England (RCSE) state the content required to form a complete medical record, but do not address legibility. An audit of otolaryngology emergency clinic record keeping was performed using a new scoring system. PATIENTS AND METHODS: The Adjusted Note Keeping and Legibility (ANKLe) score was developed as an objective and quantitative method to assess both the content and legibility of case notes, incorporating the RCSE guidelines. Twenty consecutive otolaryngology emergency clinic case notes from each of 7 senior house officers were audited against standards for legibility and content using the ANKLe score. A proforma was introduced to improve documentation and handwriting advice was given. A further set of 140 notes (20 notes for each of the 7 doctors) was audited in the same way to provide feedback. RESULTS: The introduction of a proforma and advice on handwriting significantly increased the quality of case note entries in terms of content, legibility and overall ANKLe score. CONCLUSIONS: Accurate note keeping can be improved by the use of a proforma. The legibility of handwriting can be improved using simple advice. The ANKLe score is an objective assessment tool of the overall quality of medical note documentation which can be adapted for use in other specialties. |
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Authors:
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Sara C Dexter; Daichi Hayashi; James R Tysome |
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Publication Detail:
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Type: Journal Article |
Journal Detail:
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Title: Annals of the Royal College of Surgeons of England Volume: 90 ISSN: 1478-7083 ISO Abbreviation: Ann R Coll Surg Engl Publication Date: 2008 Apr |
Date Detail:
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Created Date: 2008-04-23 Completed Date: 2008-05-29 Revised Date: 2010-09-22 |
Medline Journal Info:
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Nlm Unique ID: 7506860 Medline TA: Ann R Coll Surg Engl Country: England |
Other Details:
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Languages: eng Pagination: 231-4 Citation Subset: IM |
Affiliation:
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Department of Otolaryngology, Medway Maritime Hospital, Gillingham, Kent, UK. sara@kuruma.co.uk |
Export Citation:
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| MeSH Terms | |
Descriptor/Qualifier:
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Ambulatory Care Facilities
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organization & administration* England Forms and Records Control Handwriting Humans Medical Audit / methods* Medical Records / standards* Otolaryngology* Prospective Studies Quality Control |
| Comments/Corrections | |
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