Bhattacharjee S, Kaur G. A study on the standard of documentation of lumbar puncture in neurology department of a major Irish Teaching Hospital in Ireland.
Ann Indian Acad Neurol 2013;
16:627-30. [PMID:
24339594 PMCID:
PMC3841615 DOI:
10.4103/0972-2327.120498]
[Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2013] [Revised: 07/07/2013] [Accepted: 08/15/2013] [Indexed: 12/03/2022] Open
Abstract
Objective:
Poor documentation following lumbar puncture (LP) had always been a matter of concern. This study aimed to investigate the documentation pattern of neurology house officers, registrars (Regs), and specialist Regs following LP in a major teaching hospital.
Materials and Methods:
Total hundred patient records were examined in the light of a carefully designed proforma containing 15 important indicators of good-quality LP documentation.
Result:
Mean number of indicators overall documented by doctors was found to be 6.24 ± 3.0037. The mean number of indicators recorded by house officers was 5.11 ± 3.01 and Regs was 7.56 ± 3.28. A total of 33% LPs were performed without a documented consent. Only 36% performers documented the type and size of needle they used during the procedure. Only 46% documents revealed the strength and name of the local anesthetic used. Statistically significant difference between senior house officers and Regs in terms of numbers of indicators documented was noted.
Conclusion:
The documentation standard among neurology junior doctors remained poor.
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