Notes: a suitable case for audit.

An audit of children referred with suspected epilepsy

Members of the British Paediatric Neurology Association were invited to participate in a national audit of children presenting with a possible diagnosis of epilepsy. The audit was based on a 'standard' or set of pre-determined questions drawn up by an advisory audit group. The audit form comprised a total of 30 questions divided into four sections addressing history, examination, investigation,...

Incompleteness and retrieval of case notes in a case note audit of colorectal cancer.

Hospital case notes are a crucial source of data but are subject to two major biases: incompleteness of data and non-retrieval. To assess these biases in relation to colorectal cancer a study was performed of all cases of colorectal cancer listed in the Thames cancer registry in patients resident in one of four districts in South Thames regions with a diagnosis in 1988. Five medical record site...

Counselling of complications of termination of pregnancy within a single Trust setting.

BACKGROUND National guidelines on the care of women requesting induced abortion recommend that counselling prior to termination of pregnancy (TOP) includes information about potential complications and sequelae. Case notes of women requesting TOP in a single hospital Trust were audited for documentation of counselling about complications. As a result of this audit the integrated care pathway (I...

Hospital case notes and medical audit: evaluation of non-response.

An audit of inpatient case records and suggestions for improvements.

A study was carried out in Kuala Lumpur Hospital to review the adequacy of documentation of bio-data and clinical data including clinical examination, progress review, discharge process and doctor's identification in ten of our clinical departments. Twenty criteria were assessed in a retrospective manner to scrutinize the contents of medical notes and subsequently two prospective evaluations we...