WED 026 ‘creating a neurological exam template for acute medical admissions’

Abstract

IntroductionThere is sub optimal documentation of neurological exam findings in patient’s hospital records. Documented Neurological findings are often incomplete, omitted or scattered in various places in the clinical notes. This is important in the setting of acute neurological emergencies, where accurate documentation is vital in gauging potential deterioration/improvement in a patient’s condition.MethodA chart review was performed on 80 patients referred to the Neurology consult service in St James’s Hospital between January-February 2018. All aspects of the Neurological exam findings documented in these charts were noted. A gold standard template for accurate recording of Neurological exam findings was then created and circulated to all Hospital NCHD’s. A repeat chart review was performed on 80 patients referred to Neurology Consults between March-May 2018 (following the circulation of this template) and results were compared.DiscussionRecord keeping varied according to different clinical parameters, being lowest for speech at just over 20% and highest for muscle power at over 70%. Globally there was a small but significant improvement (P Value<0.001) in the documentation rates of neurological exam parameters following circulation of the template. We plan to apply this template to all acute medical admissions in St James’s Hospital.