Quality of clinical case note entries: how good are we at achieving set standards?

INTRODUCTION: High quality entries in case notes are becoming increasingly important. Standards exist on what information entries should contain. We have compared case notes from surgical teams at the Royal Glamorgan Hospital with standards based on guidelines from The Royal College of Surgeons of England. PATIENTS AND METHODS: A total of 120 case notes, randomly selected from the department of general surgery, were reviewed. RESULTS: An 80% compliance was achieved in 25/35 standards and 100% was achieved in 6 (patient's name, date, surgeon's name and type of operation on the operation sheet and consent form signed and dated). The following fell short of 80% compliance: PAS number on every page (75%); entries timed (27%); and clinician's name (16%) and designation (27%) printed. Social history was only recorded in 73% of clerkings and family history in 33%. Results of laboratory tests were signed in 65% of notes and radiological tests were signed in 41%. CONCLUSIONS: Healthcare professionals need to be aware of, and comply with, standards. House officers should be given information about standards at departmental induction or during medical training.