P166 Tertiary in-reach clinic documentation

Introduction In-reach clinics involve specialist paediatric clinicians who travel to Royal Belfast Hospital for Sick Children (RBHSC) from mainland UK. They undertake joint clinics with RBHSC consultants - providing specialist care for patients closer to home. The O’Hara enquiry stated record keeping should be subject to rigorous, routine and regular audit. We wanted to review the quality of documentation from our specialist in-reach clinics for several reasons. We wanted to ensure it was in keeping with standardised practice to maximise patient safety, quality of care and to support professional best practice. Methods We reviewed 20 sets of patients notes from five different speciality in-reach clinics. We reviewed the notes looking at 17 different criteria. We based our criteria on the generic medical record keeping standards produced by the Royal College of Physicians. They criteria were as follows: Was a record of clinic appointment made in the notes Which clinician present documented the clinic appointment Was the patients first and last name on each page of record Was the patients identification number present on record Was the date of clinic appointment recorded Was the time of the clinic appointment recorded Was the record signed by clinician making the entry Was the clinician’s name legibly printed Was the clinicians general medical council number printed against signature Was it documented which other healthcare professionals where present during clinic appointment Where deletions and alterations countersigned, dated and timed Was the patients medical history recorded Were the examination finding recorded Were the patients investigations recorded Was the patients diagnosis recorded Was the patients management plan recorded Was the patients clinic letter available on Electronic Care Record Results The healthcare professionals present during the clinic was documented in 35% of records. The examination findings were documented in 40% of records. The name of clinician making record was legible in 35% records. The clinicians General medical council number was documented in 10% of records. Conclusion We recognised there were areas for significant improvement on documentation. We are currently in the process of providing a proforma for in-reach clinics. This will be provided to clinicians and available in outpatient clinic rooms at Royal Belfast Hospital for Sick Children. The proforma will provide a layout for the standard of documentation which would be expected for in-reach outpatient clinic appointments.