iBet uBet web content aggregator. Adding the entire web to your favor.
iBet uBet web content aggregator. Adding the entire web to your favor.



Link to original content: http://pubmed.ncbi.nlm.nih.gov/38077659/
Medical Note Quality Audit at the Vascular Surgical Unit Compared With the British Medical Journal (BMJ) Guidelines - PubMed Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2023 Dec 7;15(12):e50110.
doi: 10.7759/cureus.50110. eCollection 2023 Dec.

Medical Note Quality Audit at the Vascular Surgical Unit Compared With the British Medical Journal (BMJ) Guidelines

Nicolette Busuttil  1 , Kevin Cassar  2   3 , Gordon Caruana Dingli  4   5 , Matthew Joe Grima  2   6
Affiliations

Medical Note Quality Audit at the Vascular Surgical Unit Compared With the British Medical Journal (BMJ) Guidelines

Nicolette Busuttil et al. Cureus. .

Abstract

Effective medical notes ensure comprehensive documentation in healthcare. This study evaluates medical note quality in the vascular unit at Mater Dei Hospital using British Medical Journal (BMJ) guidelines. Two cycles examine 17 parameters pre- and post-intervention, revealing notable, significant enhancements in patient identifiers, clinical summaries, examination, and planning. Future prospects involve digitizing note-taking, utilizing artificial intelligence (AI) for data organization, and simplifying entry methods. Implementation of electronic solutions is encouraged for improved accuracy, efficiency, and continuity of patient care.

Keywords: artificial intelligence in medical note writing; cardiothoracic & vascular surgery; electronic health records; history and physical note; medical note writing.

PubMed Disclaimer

Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Figure 1
Figure 1. Proforma for 'Ideal Note Writing'
Developed by Dr. Nicolette Busuttil, the figure is a structured compilation based on parameters derived from the British Medical Journal guidelines.
Figure 2
Figure 2. Paired t-test
t (16) = -4.0987, p < 0.001
See this image and copyright information in PMC

Similar articles

See all similar articles

References

    1. How to write in the medical notes. Brock R. BMJ. 2016;353:0. - PubMed
    1. Improving the written medical handover. Martin R, Huddart M, Garbett C, Storr W, Watts O, Gupta S. BMJ Open Qual. 2018;7:0. - PMC - PubMed
    1. The clinician's perspective on electronic health records and how they can affect patient care. Walsh SH. BMJ. 2004;328:1184–1187. - PMC - PubMed
    1. Setting the records straight--a prospective audit of the quality of case notes in a surgical department. Chamisa I, Zulu BM. https://pubmed.ncbi.nlm.nih.gov/17892187/ S Afr J Surg. 2007;45:92, 94-5. - PubMed
    1. What is a Medical Note? | Practice Fusion EHR. [ Dec; 2023 ];https://www.practicefusion.com/medical-notes/ 2015 2015:7.

LinkOut - more resources