Medical documentation in a busy UK teaching hospital eye casualty-is there room for improvement?

Abstract

When adverse events occur, documentation surrounding the incident is one of the first things to be reviewed. As a result, the UK NHS Litigation Authority [1] (NHS LA) and National Institute for Health Care and Excellence [1] (NICE) produced a set of guidelines for the expected standard of Medical Documentation. As part of the Ophthalmology team we set out to assess the quality of Medical Documentation in our Eye Casualty. This is something that has been audited in the department previously. Following on from the audit there has been a big push to increase awareness of the need for robust documentation, which has taken place at the induction of new junior doctors and Consultants as well as at Grand Round teaching.