Evaluating the Quality of Medical Documentation at a University Teaching Hospital

"Following the introduction of Electronic Patient Records (EPR) to NHS trusts and the freedom of information available to patients, the need for transparent and clear documentation is even more important. The aim of the study was therefore to evaluate the quality of medical documentation in patients’ notes across the different specialties based at the hospital."

Evaluating the Quality of Medical Documentation at a University Teaching Hospital
E Ridyard, E Street
BMJ Quality Improvement Reports 2015;4: doi:10.1136/bmjquality.u208052.w3253

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Ceiling of care decisions at an older person's mental health unit

"The issue was that decisions around ceilings of care for patients were often not discussed or at least recorded in the electronic notes and as a result when reviewing deteriorating patients out of hours trainees would find themselves without any guidance on the treating medics opinion on what was in the best interests of the patient."

Ceiling of care decisions at an older person's mental health unit in Gloucestershire
P Slack, A Rose
BMJ Quality Improvement Reports 2015;4: doi:10.1136/bmjquality.u207618.w3050

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Ward round documentation in a major trauma centre: can we improve patient safety?

"We show that our new system of note keeping for use during ward rounds in a major trauma centre improves both the quality and consistency of ward round entries. It consolidates each member of the team’s knowledge about each patient, and contributes to effective handover. "

Ward round documentation in a major trauma centre: can we improve patient safety?
G Green, A Aframian, J Bernard
BMJ Quality Improvement Reports 2014;3: doi:10.1136/bmjquality.u206189.w2537

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