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     Study
 Professor Hill’s Team
                      Introduction
 Medical notes and records were
  originally used as a reminder for doctors
  about their patient’s state of health.1
  Nowadays, it is vital that any
  documentation recorded should be made
  in accordance with the Health Service
  Executive [HSE] Records Management
  standards. This is an official document
  providing clear guidelines to help enfore
  enhanced safety measures.2
                         The Study?

A cohort study over eight days.
There were two groups; a sticker study
  group and a control group, each
  consisting of 5 consultant teams.
Based on these teams and their in-patients
  we were able to analyse data of 198
  surgical ward round notes. This totaled to
  34 study patients and 53 control patients.
                        Stickers Used?



          QuickTime™ an d a
TIFF (Uncompressed) decompressor
   are need ed to see this picture .
  How were the wardround
         notes analysed?
 We checked for thirteen variables in the
   ward round notes.
 We divided these variables into four
   groups;
1. Standard Criterion
2. Health Professional Data
3. Significant Clinical Data
4. Team Data
 These variables abide by the HSE
   guidelines and must be present in any
   form of medical documentation.
 Now for some statistics……
The Results
               1. Standard Criterion
              Stickers (69)   Control (129)
              Yes        No   Yes       No
Two Patient   69       0      89       40
Identifiers
Dated         69      0       129     0

Timed         59      0       29      100

Signed        10      0       122     7
                                                     Percentage Adherence
                                                                  Chart Review

                    120%

                             100%                    100% 100%
                    100%                                                                     94%   95%
                                                                               85%
Ward Round Note s




                    80%
                                       69%
                                                                                                         Yes (Stickers)
                    60%
                                                                                                         Yes (Control)

                    40%
                                                                                       23%
                    20%


                     0%
                           Two Patient Identifiers     Dated                       Timed       Signed
                                                               Basic Information
        2. Health Professional Data

               Stickers (69)   Control (129)
               Yes        No   Yes       No
Name Printed   69        0     1        128
and legible
Medical Council 69      0      2       127
No.
Bleep No.       69      0      120     9
                                       Percentage Adherence
                                             Chart Review

                   120
                           100               100                100
                   100                                                93
Ward Round Notes




                   80

                                                                               Y e s (Stick e rs)
                   60
                                                                               Y e s (C o ntro l)

                   40

                   20
                                  1                 2
                    0
                         Na m e P rinte d Me d ical C o uncil   Ble e p No .
                          a nd Leg ib le     Num b e r
                                         Contact Details
         3. Significant Clinical Data
               Stickers (69)   Control (129)
               Yes       No    Yes       No

Management     69      0       123     6
Plan

Abnormal       33      36      44      85
Bloods

Vitals         56      13      52      77
                                      Percentage Adherence
                                           Chart Review

                  120
                           100
                  100            95
Wardround Notes




                                                          81
                   80

                                                                    Yes (Stickers)
                   60
                                            48                      Yes (C ontrol)
                                                               40
                   40                            34


                   20

                   0
                        Management Plan Abnormal Bloods    Vitals
                                             noted
                                         Clinical Data
            4. Consultant Team Data
              Stickers (69)   Control (129)
              Yes       No    Yes       No


Most Senior   53      16      32      97
Clinician
Documented

Team Name     69      0       56      73
                                   Percentage Adherence
                                           Chart Review

                   120%

                                                    100%
                   100%
Ward Round Notes




                           77%
                   80%

                                                                     Y e s (Stick e rs)
                   60%
                                                                     Y e s (C ontro l)
                                                           43%
                   40%
                                    25%
                   20%


                    0%
                          Se nior C linicia n       T e a m Na m e
                                         Team Details
                          Average Adherence
                                 Percentage
 We calculated the average adherence percentage by adding
 Up the 13 variable and dividing it by 1300 and finally
 multiplying it by 100 :-


Control group :- 69+100+95+23+1+2+93+95+98+34+40+25+43
             = 718
             (718/1300) * 100 = 55.2%

Sticker group :- 100+100+94+85+100+100+100+100+100+48
                +81+77+100= 1186
             (1186/1300) * 100 = 91.2%
Increase in Adherence to
              Standards



            QuickTime™ and a
   TIFF (Uncompressed) decompressor
      are neede d to see this picture.
                          Conclusion

  Based on these results, we would like to
conclude that such a system can prove to be
not only cost effective, but also a highly
organised and efficient way to help adhere to
the HSE standards.
Overall increasing patient safety while
minimising the workload.
                     Thanks

 Any Questions???

				
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posted:11/17/2012
language:English
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