Abstract
Integrated care pathways (ICPs) are being widely adopted in orthopaedic surgery. This study compares the quality of medical notation in an ICP with traditional record keeping. During a 3-month period, 53 total hip replacements (ICP notation) and 30 total knee replacements (traditional notation) were performed. The records of each patient were scrutinised using a standardised scoring system, based on The Royal College of Surgeons of England guidelines on medical record keeping. Each set of records (83) was scored for: admission clerking, subsequent entries, consent form, operation note, and discharge letters. The time taken to retrieve this information was recorded. The overall score for traditional records (mean, 70%) was significantly higher (P = 0.001 ) than for the ICP records (mean, 62%). The mean scores for initial clerking, subsequent entries and consent form were higher in the traditional record group. It took 35% longer to retrieve information from the ICP group (P < 0.001). In this study, the quality of record keeping was higher when using the traditional notation than an established ICP. In both groups, the frequency of omissions was high.
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