Assessing the Correct Documentation of Time and Physician Information on Medical Records in the Emergency Department of Queen's Hospital: An Audit and Re-audit

Abstract

Background: Medical records are confidential medical and legal documents describing a patient's contact with a healthcare facility. The quality of documentation has been found to be lower in settings of high patient volume and complex cases, such as the emergency department (ED). The variety and number of healthcare professionals involved in the care of the patient also negatively affect the quality of documentation. The aim of this paper is to present the results of an audit and re-audit conducted in the ED of Queen's Hospital, Romford, to assess ED record documentation against General Medical Council (GMC) and Royal College of Physicians (RCP) standards.