Daily progress notes by surgical interns: an assessment of quality

ABSTRACT

To evaluate the quality of daily progress notes documented by surgical interns in a tertiary care teaching hospital. Daily progress notes documented by interns during two months period from February to March 2008 were assessed according to the guidelines developed by the Unit. During each working day progress notes were evaluated in a specially designed proforma about documentation, which included subjective, objective, assessement and plan. Data was analysed by SPSS version 10 and Chi square test was applied between categorial data. Two hundred fifty patient's record were assessed for daily progress notes. Out of them 44 [17.6%] daily notes were not found, so a total of 206 morning follow up notes were analyzed. These included 63 [30.6%] preoparative and 143 [69.4%] postoperative patient notes. Most common documented variable was Blood Pressure reading in 194 [94.2%] notes followed by pulse rate in 193 [93.7%]. The leaset documented variable was assessement of patient's current condition in 111 [53.9%] patients' notes. There was statistical significant difference between quality of notes in preoperative patients as compared to postoperative patients. Overall no significant difference was noted while comparing elective vs emergency surgery patient's notes and hepatits positive vs negative notes. Our results showed that our documentation as regards daily progress notes was overall fair. Systematic audit of this type can lead to the development of improved documentation supporting the clinical process within a busy general surgical department with benefits for patient care, clinical governance and inter-specialty communication