The ANKLe score: an audit of otolaryngology emergency clinic record keeping.

Annals of the Royal College of Surgeons of England
Sara C DexterJames R Tysome

Abstract

Accurate and legible medical records are essential to good quality patient care. Guidelines from The Royal College of Surgeons of England (RCSE) state the content required to form a complete medical record, but do not address legibility. An audit of otolaryngology emergency clinic record keeping was performed using a new scoring system. The Adjusted Note Keeping and Legibility (ANKLe) score was developed as an objective and quantitative method to assess both the content and legibility of case notes, incorporating the RCSE guidelines. Twenty consecutive otolaryngology emergency clinic case notes from each of 7 senior house officers were audited against standards for legibility and content using the ANKLe score. A proforma was introduced to improve documentation and handwriting advice was given. A further set of 140 notes (20 notes for each of the 7 doctors) was audited in the same way to provide feedback. The introduction of a proforma and advice on handwriting significantly increased the quality of case note entries in terms of content, legibility and overall ANKLe score. Accurate note keeping can be improved by the use of a proforma. The legibility of handwriting can be improved using simple advice. The ANKLe score is an objec...Continue Reading

References

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Citations

May 9, 2014·The Journal of Chiropractic Education·Nicole M HombKurt Wood
Jul 14, 2009·The Journal of Laryngology and Otology·S J C FishpoolL A C Hicklin
Feb 13, 2018·British Journal of Hospital Medicine·Deborah OwenDennis Kosuge
Jan 29, 2019·Emergency Medicine Australasia : EMA·Fiona Wy LaiDavid McD Taylor
Oct 22, 2018·Irish Journal of Medical Science·Lava ChalikondaJohn O'Byrne
Dec 19, 2018·BMC Emergency Medicine·Diane L LorenzettiCynthia A Beck

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Software Mentioned

ANKLe
CRABEL

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