WHERE THIS HAPPENED: Basildon and Thurrock University Hospital NHS Trust
With the advent of electronic discharge letters, many components of the CRABEL score for auditing medical records have been made redundant as computers automatically include some documentation. Assessment of and prophylaxis against venous thromboembolism risk (VTE) is now meant to be undertaken at the time of admission of all medical and surgical patients.
Despite this, it is still something that is occasionally not done for hours or days after a patient has arrived on a ward. A sufficiently compact and modern tool is required in order to investigate standards of record keeping regularly over a long term period.
Three foundation doctors and a surgical consultant set out to use a compact tool to monitor the quality of medical records of surgical patients to give a numerical score, and improve this score over the course of the six months across all six surgical subspecialties at a busy surgical unit at Basildon and Thurrock University Hospital.
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With the advent of electronic discharge letters, many components of the CRABEL score for auditing medical records have been made redundant as computers automatically include some documentation. Assessment of and prophylaxis against venous thromboembolism risk (VTE) is now meant to be undertaken at the time of admission of all medical and surgical patients.
Despite this, it is still something that is occasionally not done for hours or days after a patient has arrived on a ward. A sufficiently compact and modern tool is required in order to investigate standards of record keeping regularly over a long term period.
Three foundation doctors and a surgical consultant set out to use a compact tool to monitor the quality of medical records of surgical patients to give a numerical score, and improve this score over the course of the six months across all six surgical subspecialties at a busy surgical unit at Basildon and Thurrock University Hospital.
FIND OUT MORE
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