Authors (including presenting author) :
Cheng CS(1), Ho WF(1), Sy HP(1), Ng SW(1), Wang HL(1), Tsui WS(1), Kwong SK(1), Ko WK(1)
Affiliation :
(1) Family Medicine and Primary Health Care, Queen Mary Hospital, Hong Kong West Cluster
Introduction :
Medical consultation note is a medicolegal document that serves as an important source of patient information to ensure a good continuous care. Therefore, their quality does matter and should be kept up.
Objectives :
The aim is to evaluate the quality of doctors’ consultation notes in GOPCs of our department, and to find out areas of inadequacies and suggest measures to improve accordingly.
Methodology :
This study is a consultation note review of all doctors in the department. It was conducted by 4 designated auditors. For each doctor studied, 10 patients (6 followed up for chronic diseases and 4 non-follow up ones) were selected randomly. 1 record within the past 1 year was checked randomly for each of the cases chosen. 14 criteria were set up to analyze the record quality. Range of scoring for each criterion was 0, 1 and 2 (highest). In order to standardize the scoring, various case scenarios had been discussed and consensus obtained among all auditors before the study commences.
After the score collection, analysis was conducted to figure out the aspects of deficiency amongst all doctors and differences between various groups e.g. training level, follow up vs non-follow up cases etc. Results were then anonymously shared with doctor colleagues and consensus reached on improvement measures in our monthly meetings. Individual feedback on scores was also conveyed in separate emails.
Result & Outcome :
The 3 criteria with the lowest overall average score are ‘ICPC codes +/- diagnostic impression(s) or problem list(s)’ (score: 1.67), ‘investigation results (if available)’ (score: 1.70) and ‘presence of associated positive and negative clinical features’ (score: 1.72), the last of which being the most omitted one. Our colleagues tend to do better for chronic follow up cases than non-follow up ones. Further, it is found that specialists’ records score higher than non-specialist colleagues. Concerning the difference among various ranks, resident specialists and associate consultants have a higher level of overall performance.
A few improvement measures were suggested and agreed in response to the results. These include documentation of crucial positive and negative clinical features that guide us to the diagnosis(es) / diagnostic impression, correct ICPC codes and a gross diagnostic impression even when a certain diagnosis cannot yet be made. Moreover, apart from encouraging colleagues to state in the notes the correct dates for investigation(s) done, annual assessment results should also be documented in the patient summary for easy future reference.
Co-location with:
