|Dr Leena Aggarwal
Title: Quality of Documentation in Medical Records
1 Director of Medical Assessment and Planning Unit, Princess
Alexandra Hospital, Brisbane, QLD, Australia
Aim: An audit of
medical charts was carried out to review quality of admission and progress
notes by the medical team in order to identify current deficiencies,
inconsistencies and discrepancies.
descriptive review of medical records was conducted in first half of January
2016 at an acute medical unit in a tertiary hospital in Brisbane. Documentation
of history& clinical examination, investigations, treatment and
alerts/allergies was noted in the admission notes. Subsequent entries were screened
for documentation of clinical progress and subsequent plan of care. All the
discharge summaries were also scrutinized for documentation of details of
patient & treating clinician along with
details of diagnosis, significant investigations, procedures done and
medications on discharge.
Results: Most of the
admission records by medical registrar had adequate clinical and contact
details but documentation of medication history could have been
better.Interestingly, nearly half did not have any provisional diagnosis
reflecting lack of confidence/expertise amongst the registrars. Subsequent
medical entries were lacking in details regarding clinical findings &
investigations (nearly 50%) with very poor documentation of the name of the
senior clinician (20%) Discharge planning commenced on admission in an acute,
rapid turnover unit only in 10% of cases. Around 10% of patients did not have a
discharge summary even 3 months after discharge. Discharge summary was sent to
the GP in nearly half of the patients within 48 hours. Most of the discharge
summaries had details of the treating clinician, GP, diagnosis, current
complications and co-morbidities and discharge plan but documentation of
allergies/alerts was poor at 20%. There was room for improvement in documentation
of investigations and medications on discharge.
Documentation of important clinical information was modest at our
hospital and requires improving staff skills and practices in clinical
documentation. Poor documentation in medical records might reduce the quality
of care and may have medico-legal consequences.
Title: Elderly Patients with Type 2 Diabetes Mellitus: Role of HBA1C as Predictor of Hypoglycaemia
1Director of Medical Assessment and Planning Unit, Princess Alexandra Hospital, Brisbane,
identify the prevalence of tight glycaemic control in elderly patients with
type 2 diabetes mellitus and characterise the population at risk for
retrospective observational study was performed over 6 months, January to June
2015 at Acute Medical Unit, Princess
Chart review of diabetic patients over the age of 65 was performed to compare the
demographics of patients with poor glycaemic control and /or hypoglycaemia with
those having adequate control.
total of 294 patients were reviewed with male:female ratio of nearly 1:1 and
mean age of 77 years. Nearly 60% were on hypoglycaemic agents and one-fourth on
insulin. Around one-fourth had very tight glycaemic control with HbA1c of
<6.5%. In all, 42 patients had in-hospital hypoglycaemia. Half of these
patients did not have their diabetic medication reviewed and nearly one-fourth
died within 12 months.
characteristics were analysed using Pearson’s chi-square. In-patient documented
hypoglycaemia (BSL<4mmol/L) was more likely to be associated with increasing
burden of co-morbidities (p=0.002), chronic kidney disease (p=0.029),
microvascular complications (p=0.02) and recurrent hospital admissions (p=0.037).
There was a three-fold increased risk of mortality in this group (p=0.005, OR
3.05, CI 1.36-6.80). Increasing age had more stringent BSL control and higher
usage of sulfonylureas +/- insulin which may prove to be counterproductive (p=0.006,
p=0.046). Surprisingly, HbA1c was not a good predictor of hypoglycaemia and
complications in this cohort. Patients on sulfonylureas and insulin were
approximately twice as likely to develop hypoglycaemia (p<0.001). Multiple
logistic regression was performed to develop a predictive scoring system for
of type 2 diabetes mellitus in elderly patients is prevalent and less
recognised as well as under-reported resulting in frailty, disability and poor
outcomes. A conservative approach to glycaemic targets in frail older people
may be worthwhile.