Medical Record Review - And another thing...

A few weeks ago, when I was discussing ECT visiting with some ECT visitors (!), among the things we discussed were about reviewing the medical notes written by the registrar about the consultation that had just been observed. It struck us that there may not be many opportunities to relate the medical record you're reading to what actually happened in the consultation (who actually said what and in what tone of voice, what were they thinking at that point).

The medical record review could also be used in conjunction with direct observation, or even better, some consultation videos. Were the important bits of the consultation recorded in the notes? Does it reflect what happened. This could be a very powerful bit of learning for the registrar - particularly if you think their notes could be better.

Medical Record Review

Welcome to the first issue of Tips on TREAT. This is going to be a regular e-mail highlighting a single assessment tool on TREAT each issue. As you may remember, TREAT, is the Wentwest Trainer-Registrar Education Assessment Toolkit, and can be found here: www.wentwest.com/treat

I intend sending out an e-mail like this regularly. Feel free to send me feedback, or to let me know if you don’t want to receive the e-mails any more. Similarly, send these on to others if you think they might be interested. You’ll find these e-mails archived on www.tipsontreat.blogspot.com

The tool for today is the Medical Record Review, which can be found here: http://www.wentwest.com/treat/index_files/Page767.htm

This tool helps supervisors to assess and feedback to registrars what their medical record keeping is like. It looks at individual consultations and the overall record.

It points up the following for discussion:
Individual records made by the registrar
Records made over a longer period of time (2 yrs in the example, but for registrars would be shortened to the length of their attachment so far)
Allows discussion of what makes for a good medical record
Selected components – referral letters (though TREAT has another tool for doing this) certificates, reports, managing results etc.

There are also suggestions about how to discuss this with a registrar, though I would think that your imagination is the only limit in ways of doing this.
Discussions starting on the medical record review could take in
Medico-legal issues – what if something went wrong in this consultation? How much would you recall about what happened? What would a court or lawyer or expert witness think?
Use of the computer – adding recalls, actions, tracking results
Managing results – what happens when a registrar notes an abnormal result?
Could another doctor take on the management based on these notes?
These issues will all link in together, but the emphasis might be different depending on the needs of that registrar.

Have a go at this tool with your registrar! Remember, this is not compulsory. And do feel free to e-mail feedback about the tool or the website, or any suggestions or questions, or if you’d rather not receive the e-mails.