The Use of a Structured Form during Urology Out-patient Consultations

Summary

Objectives: To compare the completeness of documentation in the medical record using a structured form (SF) versus a traditional medical record (TMR).

Methods: Randomised controlled trial comparing the use of SF and TMR in urology out-patient clinics for documentation of 15 items of clinical information, time taken to complete and acceptability to clinicians assessed by a self-completion questionnaire. in a teaching and district general hospitals

Results: Four hundred new urology patient consultations, 11 clinicians. Completeness of information was compared between groups based on the medical record alone (SF vs. TMR), medical record plus letter to GP and letter alone. SFs were significantly (p<0.0001) more complete than TMRs for the majority of the items in all three groups. There was no significant difference in the time taken to document information using either type of record. The clinicians generally found the SF acceptable for routine use.

Conclusions: Structured forms significantly improved the completeness of documentation for new out-patient consultations in urology.

Keywords

Medical record - structured form - documentation - audit - proforma - out-patient

• References

• 1 Fernando KJ, Siriwardena AK. Standards of documentation of the surgeon-patient consultation in current surgical practice. Br J Surg 2001; 88: 309-12.
• 2 Cox JL, Zitner D, Courtney KD, Mac Donald DL, Paterson G. et al Undocumented patient information: an impediment to quality of care. Am J Med 2003; 114: 211-6.
• 3 Schott S. How poor documentation does damage in the courtroom. J AHIMA 2003; 74: 20-4.
• 4 Carroll AE, Tarczy-Hornoch P, O’Reilly E, Christakis DA. Resident documentation discrepancies in a neonatal intensive care unit. Pediatrics 2003; 111: 976-80.
• 5 Roberts CM, Lowe D, Bucknall CE, Ryland I, Kelly Y, Pearson MG. Clinical audit indicators of outcome following admission to hospital with acute exacerbation of chronic obstructive pulmonary disease. Thorax 2002; 57 (02) 137-41.
• 6 Nicopoullos JD, Karrar S, Gour A, Panter K. Significant improvement in quality of caesarean section documentation with dedicated operative proforma- completion of the audit cycle. J Obstet Gynaecol 2003; 23 (04) 381-6.
• 7 Kafrawy U, Stewart D. An evaluation of brainstem death documentation: the importance of full documentation. Paediatr Anaest 2004; 14 (07) 584-8.
• 8 Scherer R, Zhu Q, Langenberg P, Feldon S, Kelman S, Dickersin K. Comparison of information obtained by operative note abstraction with that recorded on a standardized data collection form. Surgery 2003; 133: 324-30.
• 9 Hamill J, Paice R, Civil I. Trauma form documentation in major trauma. N Z Med J 2000; 113: 146-8.
• 10 O’Connor AE, Finnel L, Reid J. Do preformatted charts improve doctors’ documentation in a rural hospital emergency department? A prospective trial. N Z Med J 2001; 114: 443-4.
• 11 Thomas K, Emberton M and Mundy AR. Towards a minimum dataset in urology. BJU Int 2000; 86: 765-72.
• 12 Royal College of Surgeons of England. Guidelines for clinicians on medical records and notes. London, Royal College of Surgeons of England 1994
• 13 Audit Commission. Setting the records straight: a study of hospital medical records. London: HMSO; 1995