In total, 4 wards took part in the audit in February 2022, providing information on 60 inpatients. 4 wards participated in the April 2022 re-audit, making the data indicative of 60 inpatients ( 120 total in the two cycles ) . When the data was compiled for the hospital, an overall compliance rate for each of the 37 audit standards was calculated. Results for all standards were categorized into three indicators and coded using the system outlined in Box 1 in both February and April cycles . Table 1 displays the percentage of standards that fell into each category when the results were compiled for the RUH. This audit summary shows that compliance seems to be continuously improving. There are now fewer moderate standards and more high standards . however, there are still a number of areas in moderate category of documentation practice where improvements can be made. 35 of the 37 audit standards had higher compliance level in April 2022 than they were in the previous audit. The section of the documentation that details urine output was completed in 100% of cases, which represented the highest improvement in compliance at 76.7%. (23.3% in February 2022 ) . No standard or criterion's compliance dropped during the re-audit cycle in April 2022. Since the first audit cycle, compliance has increased on average by 32% across all audit criteria, suggesting that some of the work done after the first cycle has had a significant effect. Looking back at the suggestions made following the February cycle, they provide more proof of the practice improvement between February and April.. The recommendations are mentioned in Table 2 along with the steps taken to guarantee successful implementation. The outcomes illustrate how the actions have enhanced compliance. All these instances demonstrate that, when followed, recommendations from documentation audit can have a good influence, even though there is still room for improvement. Additional data analysis revealed that both in the February and the April cycles, both excellent and bad practice tended to be consistent across RUH . For the same standards, many wards found low and moderate outcomes. This prompted more evaluation to understand if the patient's risks were rising as a result of the low performance. – Box 2 clarified this. This risk evaluation, conducted by the deputy head doctor, revealed that in some instances, doctors' time was being wasted filling out data that was unrelated to the patient's care. Sometimes the demands on a doctor's time to complete such information can be devastating to patient care and can lower the overall standard of documentation. The risk assessment was helpful because it made it easier to tell the difference between issues with documentation practice and issues with the documentation forms. When formulating the recommendations for future practice, this extra information was essential since, in some situations, it was the structure and content of the patient documentation forms that required modification rather than the way previous records were kept.
Table 1. Standards in each three-category indication
|
Indicator
|
Percentage of standards for February
|
Percentage of standards for April
|
High
(80–100% compliance)
|
45.9% ( 17 )
|
89.1% ( 33 )
|
Moderate
(50–79% compliance)
|
21.6% ( 8 )
|
10.8% ( 4 )
|
Low
(<50% compliance)
|
32.4% ( 12 )
|
0% ( 0 )
|
Table 2. Recommendations and actions from February 2022 & April 2022 audit
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Recommendations
|
New elements have been added to the patient documentation forms, many of which have been recognized as requiring improvement. It is necessary to the professional and practice development unit to offer instruction and training on the new assessment documentation and how to complete it.
Raising awareness among the surgical staff for the importance of accurate record-keeping from the perspectives of patient care and research.. [6]
Consultants should frequently review and assess patient files to ensure complete and accurate record completion.
The team responsible from the statistical quality control should monitor and evaluate all records.
|
Action taken
|
To assist staff members at Ribat University Hospital in comprehending and effectively completing documentation forms, education and training have been made available..
To help with these documentation concerns, awareness raising has been done, including looking into the potential legal consequences of inadequate documentation..
|
February 2022 audit compliance
|
• General improvements – see Table 1
• Urine Output documentation were completed in 23.3% of cases
• Input and output charts documentation were completed in 23% of cases
• Entries dated in 86.2% of cases
• Entries timed in 34.5% of cases
|
April 2022 audit compliance
|
• General improvements – see Table 1
• Urine Output documentation were completed in 100% of cases
• Input and output charts documentation were completed in 66.7% of cases
• Entries dated in 100% of cases
• Entries timed in 100% of cases
|
Box 2. An example of risk evaluation of audit results
|
Indicator
|
Percentage completed
|
Risk to patient
|
Need
|
Drug Allergies
|
82.5 %
|
High
|
High
|
Marital Status
|
13.3 %
|
Low
|
Low
|
In this illustration, it is clear that even while there is high compliance for drug allergies, there is a substantial threat to the patient in the 19% of applicable cases where this information was not recorded. Contrarily, adherence with demands for specific information about a patient's marital status is substantially lower, but in terms of their care, this poses a far lower danger.
|
Dissemination of results :
Data from the audit and re-audit were made available through a number of channels. ( including face to face presentation and poster format ) in May 2022 . The results were presented to :
· The clinical surgical staff meeting.
· The clinical management board.
· The statistical quality control department.
Recommendations for future practice :
The results of the audit and the risk assessment were discussed with the various stakeholder groups involved at the above meetings during the dissemination sessions. Following these discussions, the following major recommendations for future practice were created:
1. To ensure the gathering of crucial data and minimize duplication, the initial patient evaluation record must be reduced.
2. The initial patient evaluation documentation now uses a trigger section approach that only prompts a more in-depth review when necessary.
3. To rationalize and standardize charts and checklists, a record-keeping sub-group is immediately established.
4. Work is done jointly with the hospital governance team to enhance the documentation of low compliance standards in records.
5. A discharge day form has been established, and documentation guidelines for discharge planning are being created.
6. Each directorate should evaluate the risks associated with their local outcomes, compare them to the RUH data, and identify important actions for measurable changes in their future practice from all of their recommendations. The next audit should then evaluate the progress made in these areas.
7. The RUH education and development team will continue to provide regular training sessions for doctors' personnel in all clinical areas on how to properly use patients' documentation, as well as the patient safety and legal issues related to improper records practices. The adoption of such training will be essential to enhancing record keeping procedures.
8. The following re-audit will include a more thorough review of all the documentation, including the discharge prescription form, fluid balance chart and peak flow chart.
The clinical management board members are now implementing these recommendations Although , at the monthly meetings, there are frequent reports on the status of these topic.