A closed loop audit to analyse the documentation by medical and healthcare staff in clinical oncology patients to assess quality of inpatient documentation against a standard set by the GMC and the RCP

摘要

The main focus of healthcare delivery is to ensure patient safety while practising evidence-based medicine. While doing so the medicolegal safety of the healthcare professional is also of utmost importance. We noticed that a large number of E-noting entries made for inpatients did not have enough information to ascertain accountability for that entry. This intrigued us to look into set standards for documentation and then compare them to practice generally adopted on the ward to assess if these standards were being met.