Medical record keeping and system performance in orthopaedic trauma patients

A Clinical Audit of Orthopaedic Clinical Documentation of Acute Ankle Fractures: A Quality Improvement Project

Background Orthopaedic ankle fractures are common injuries that require careful assessment, management, and documentation to ensure optimal patient outcomes. Proper documentation plays a critical role in facilitating communication among healthcare professionals, ensuring accurate diagnosis, treatment planning, and monitoring patient progress. Moreover, it is essential for medico-legal purposes and quality improvement initiatives. This article presents a comprehensive clinical audit aimed at evaluating the quality of orthopaedic ankle fracture documentation within a healthcare setting. The aim of this project was to assess the quality and accuracy of ankle fracture documentation within a single centre against the audit standards set by the British Orthopaedic Association (BOA) and the National Institute for Health and Care Excellence (NICE). Methods The study was a closed-loop audit utilising both retrospective and prospective analysis of ankle fracture clerking documentation performed by members of the trauma and orthopaedics team. Two audit cycles were completed in total; the first cycle was carried out in January 2020 where data were collected retrospectively from all orthopaedic admissions of ankle fractures. This was then re-audited against the BOA and NICE guidelines and presented to the local clinical governance meeting. A targeted educational intervention was then implemented with the goal of educating and reinforcing to key team members the documentation standards and the importance of accurate clerking documentation. The second cycle was carried out during July 2020 prospectively. All data were collected and collated with a total of nine data parameters analysed. Patients were included if they were skeletally mature and presented with closed malleolar and syndesmotic ankle injuries. Excluded patients were those who presented with open fractures, pilon fractures, and/or were skeletally immature. Data were then re-presented at the clinical governance meeting. Results A total of 23 patients were identified in the initial audit cycle and 22 patients in re-audit. On admission, it was found that 86% of patients presenting with ankle fractures had adequate documentation of their injury mechanism, which subsequently improved to 100% following the intervention. Similarly, there was a 71% improvement in precise documentation of clinical findings of ankle fractures. There was a marked improvement in the consistency of examination findings as well, with over 30% improvement in the rate of documentation for sensation status, skin integrity, circulation, and motor function. Results also revealed a 71% improvement in the documentation rates of vascular examinations where a Doppler ultrasound was used or pulses named in the documentation. Conclusion Through a targeted educational scheme focussing on the proposed documentation guidelines, we noted a significant improvement in documentation standards and accuracy of ankle fractures in the trauma and orthopaedic department. With ongoing educational input and reinforcement, team members can be supported to maintain a high level of documentation that meets all available standards, which will ultimately lead to improved patient care.

Comparison of the quality of documentation between electronic and paper medical records in orthopaedic trauma patients

ObjectiveThe medical record is critical for documentation and communication between healthcare professionals. This study compared the completeness of orthopaedic documentation between the electronic medical record (EMR) and paper medical record (PMR).MethodsA review was undertaken of 400 medical records (200 EMR, 200 PMR) of patients with operatively managed traumatic lower limb injury. The operative report, discharge summary and first and second out-patient reviews were evaluated using criteria designed by a senior orthopaedic surgeon and senior physiotherapist. The criteria included information deemed critical to the post-operative care of the patient in the first 6 weeks post-surgery.ResultsIn all cases, an operative report was completed by a senior surgeon. Notable findings included inferior documentation of patient weight-bearing status on the operative report in the EMR than PMR group (P = 0.018). There was a significant improvement in the completion of discharge summaries in the EMR compared with PMR cohort (100% vs 82.5% respectively; P < 0.001). In the PMR group, 70.0% of discharge summaries were completed and adequately documented, compared with 91.5% of those in the EMR group (P < 0.001). At out-patient review, there was an improvement in documentation of weight-bearing instructions in the EMR compared with PMR group (81.1% vs 76.2% respectively; P = 0.032).ConclusionThe EMR is associated with an improvement in the standard of orthopaedic medical record documentation, but deficiencies remain in key components of the medical record.What is known about the topic?Medical records are an essential tool in modern medical practice and have significant implications for patient care and management, communication and medicolegal issues. Despite the importance of comprehensive documentation, numerous examples of poor documentation continue to be demonstrated. Recently, significant changes to the medical record in Australia have been implemented with the conversion of some hospitals to an EMR and the implementation of the My Health Record.What does this paper add?Standards of patient care should be monitored continuously and deficiencies identified in order to implement measures for improvement and to close the quality loop. This study has highlighted that although there has been improvement in medical record keeping with the implementation of an EMR, the standard of orthopaedic medical record keeping continues to be below what is expected, and several key areas of documentation require improvement.What are the implications for practitioners?The implications of these findings for practitioners are to highlight current deficiencies in documentation and promote change in current practice to improve the quality of medical record documentation among medical staff. Although the EMR has improved documentation, there remain areas for further improvement, and hospital administrators will find these observations useful in implementing ongoing change.

Comparison of health literacy in privately insured and public hospital orthopaedic patients

Objective The aim of the present study was to quantify and compare patient health literacy between privately insured and public orthopaedic patients. Methods As part of the present cross-sectional study, elective postoperative orthopaedic patients across two sites were recruited and asked to complete a questionnaire at the first postoperative out-patient review. Patients were divided into three groups: (1) a public group (Public); (2) a private group (Private-pre); and (3) a private group that completed the questionnaire immediately after the out-patient review (Private-post). The questionnaire consisted of six questions regarding surgical management, expected recovery time and postoperative instructions. Patients were further asked to grade their satisfaction regarding information received throughout their management. Results In all, 150 patients completed the questionnaire, 50 in each of the three groups. Patients in the Public, Private-pre and Private-post groups answered a mean 2.74, 3.24 and 4.70 of 6 questions correctly respectively. The Private-pre group was 1.46-fold more likely to demonstrate correct health literacy than the Public group, whereas the Private-post group was 2.44-fold more likely to demonstrate improved health literacy than the Private-pre group. Patient satisfaction with information received was not associated with health literacy. Conclusion Limited health literacy in orthopaedic patients continues to be an area of concern. Both private and public orthopaedic patients demonstrated poor health literacy, but private patients demonstrated significant improvement after the out-patient review. What is known about the topic? Limited health literacy is a growing public health issue worldwide, with previous literature demonstrating a prevalence of low health literacy of 26% and marginal health literacy of 20% among all patient populations. Of concern, limited health literacy has been shown to result in a range of adverse health outcomes, including increased mortality and chronic disease morbidity. It has also been associated with an increased rate of hospitalisation and use of healthcare resources. Previous work in the orthopaedic trauma setting has found poor levels of health literacy and poor understanding of diagnosis, management and prognosis in the Australian public health system. Promisingly, it has been shown that simple, targeted interventions can improve patient health literacy. What does this paper add? This study further highlights that health literacy exhibited by orthopaedic patients is poor, particularly among patients in the public healthcare system. The present study is the first to have demonstrated that health literacy is poor among patients in both the public and private healthcare systems, despite these patients having distinctly different demographics. Promisingly, the present study shows that, unlike public orthopaedic out-patient review, private orthopaedic out-patient review appears to be effective in increasing patient health literacy regarding their orthopaedic condition and its management. What are the implications for practitioners? Health literacy is essential for patients to effectively communicate with doctors and achieve good health outcomes. Healthcare professionals need to be aware that a large proportion of patients have poor health literacy and difficulty understanding health-related information, particularly pertaining to that surrounding diagnosis, management and prognosis. This study highlights the need for healthcare professionals to ensure that they communicate with patients at an appropriate level to ensure patient understanding during the pre-, peri- and postoperative stages of management. Further, healthcare professionals should be aware that there is potential to improve patient health literacy at routine out-patient review, provided that this opportunity is used as an educational resource.