ArticleIrish journal of medical science2019
An assessment of the quality of clinical records in elective orthopaedics using the STAR score.
Article in Irish journal of medical science, 2019. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 7 papers.
What it found
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
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Who cites it
7 citing papers in PubMed.
- Article
- Assessment of the quality of oral squamous cell carcinoma clinical records in oral surgery with Surgical Tool for Auditing Records (STAR) scoring.BMC oral health · 2024Article
- A Hospital Medical Record Quality Scoring Tool (MeReQ): Development, Validation, and Results of a Pilot Study.Healthcare (Basel, Switzerland) · 2024Article
- A Closed-Loop Clinical Audit of Surgical Documentation of Inpatient Records at a Tertiary Level Hospital in Egypt.Cureus · 2023Article
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Corrections and comments
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Authors and funding
3 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundLitigation claims related to surgery have increased significantly in recent years. Despite the medico-legal importance of clinical records, there have been few published studies describing the quality of medical records in orthopaedic surgery. This study aimed to evaluate the quality of clinical note taking in an elective orthopaedic setting over a 10-year period by comparing medical records from 2003 and 2013.
methodsWe used the previously validated Surgical Tool for Auditing Records (STAR) on a sample of 20 medical records from each year. We performed statistical analysis to determine if significant differences existed between 2003 and 2013.
resultsThere was an overall improvement in the quality of medical records from 76.7% (range 68-82%) in 2003, to 81% (range 72-88%) in 2013 (P value < 0.05). There were significant improvements in the subsequent entry score, from 5.15 to 6.3 (P value < 0.05) and discharge summary score, 6.65 to 7.95 (P value < 0.05). The score for the operative record section decreased from 8.45 to 8.0 (P value < 0.05).
conclusionThe overall standard of medical records in both 2003 and 2013 was high and comparable to other surgical specialties. There was no possible correlation observed between standards of medical records and increasing litigation claims in surgery. Widespread implementation of Electronic Medical Records (EMRs) is likely to have a significant impact on the quality of medical records. Further research is required to determine how the design of EMRs influences how healthcare professionals record data.
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