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22 A step forward in cardiology admissions
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  1. Bupe Chisanga,
  2. Andrew Brocklehurst,
  3. Akhlaque Uddin
  1. Nottingham University Hospital

Abstract

Background Majority of the admissions to an acute cardiac unit (ACU) happen out of hours and hence the initial assessments (clerkings) are performed by the out of hours team. Good record keeping is of interest due to patient safety and quality of care delivery. The Royal college of Physicians has set out standards of medical record keeping. This project looked at whether implementing a standardised proforma on the ACU improved the quality of the junior doctor assessment.

Methods A questionnaire was designed and used to assess the general clerking on consecutive admissions. The questionnaire looked at three broad domains that included – patient demographics, patient history and examination, and investigations. Answers to the questionnaire were marked as ‘yes’, ‘no’ or ‘n/a’. Following these results, a standardised proforma was designed and implemented. A comparison was then made between general clerking and the standardised proforma. The Results were analysed using the summary independent samples T-test.

Results Nineteen case notes were identified with general clerking; 24 case notes were identified which used the standardised proforma. There was a marked improvement in the clerking with the standardised proforma. There was an increase in documentation of coronary artery bypass graft (CABG) details from 0% to 100% (p<0.01), the smoking history documentation increased from 84% to 96% (p<0.01), the advice given in relation to smoking history increased from 0% to 40% (p<0.01), driving history increased from 11% to 50% (p<0.01), and occupation history increased from 42% to 75% (p<0.01). The junior doctors who used the proforma had overall satisfaction with the proforma with 100% giving a rating of 3 to 5 out of 5. Also, 75% (6/8) indicated that they would like to continue using it.

Conclusions The implementation of the proforma improved the overall quality of clerking of the admissions to ACU and was received well by the junior doctors.

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