Quality of surgical case notes at Dow University Hospital according to modified ANKLe score

Masood Jawaid,Zubia Masood,Abdul Khalique,Nighat Bakhtiar

doi:10.12669/pjms.294.3813

Abstract

To find out quality of surgical case notes according to modified Adjusted Note keeping and Legibility (ANKLe) score in Dow University Hospital. For this audit, medical records of all the patients admitted in Dow University Hospital surgery department were reviewed from February 2012 to April 2012. The modified ANKLe score (total 24) is formed by the combination of, the content (out of 20) and legibility (out of 4) to give an overall score out of 24. A score of at least 20 (content score 17/20; legibility score 3/4) is considered as acceptable. It means that a surgical record is legible and the majority of the essential content is recorded. A total of 236 records were evaluated. Overall mean ± standard deviation (SD) of ANKLe score was 18.4± 2.1 out of maximum score of 24. Content and legibility has overall mean scores of 14.4 out of 20 and 3.9 out of 4 respectively. Only two variables, patient's name and consultant on call were documented in 100% of records while the least documented variable were social history 2 (0.2%). Legibility scoring system provides that 218notes out of total set of 236 notes (that is 92.4% of overall notes) have achieved a score of 4. The benchmark of 80% was achieved in 26.1% for total ANKLe score, 6.8% for contents and 99.1% for legibility. Overall, quality of records is not good but legibility part scores exceptionally high.

Highlights

One of the primary skills required for good clinical practice is good medical record keeping
This study was about the quality of case note being assessed using the modified ANKLe Score.[5]
Legibility scoring system provides that 218 notes out of total set of 236 notes achieved a score of 4, indicating that quality of handwriting score is legible and clean (Table-II)

Summary

Introduction

One of the primary skills required for good clinical practice is good medical record keeping. The development of a new dimension in the context of health sector has required medical record to be considered as a back bone in the overall process. Its importance is confined to the care for day to day patients, but has been extended to the fields of research, audit and legal purposes of medical.[1] The accountability for maintaining an accurate, complete and legible records lies with all the members of the medical team.[2] In surgery, especially it is considered very essential to maintain good documentation in the operation note.[3] Once the notes are being filed, they will not be altered and in case if any change in the patient’s condition or the plan of management has to be recorded, a following entry will be made in the records

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Conclusion