Dr Leena Aggarwal
PA Hospital 


Title: Quality of Documentation in Medical Records
Aggarwal L1
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.

Methods: Retrospective 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.

Conclusions:  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

   Aggarwal L1

   1Director of Medical Assessment and Planning Unit, Princess Alexandra Hospital, Brisbane, QLD, Australia

Aim: To identify the prevalence of tight glycaemic control in elderly patients with type 2 diabetes mellitus and characterise the population at risk for hypoglycaemia.

Methods: A retrospective observational study was performed over 6 months, January to June 2015 at Acute Medical Unit, Princess Alexandra Hospital. 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.

Results: A 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.

Patient 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 in-patient hypoglycaemia.

Conclusions: Overtreatment 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.