alexa Abstract | Good Medical Record Keeping

International Journal of Collaborative Research on Internal Medicine & Public Health
Open Access

OMICS International organises 3000+ Global Conferenceseries Events every year across USA, Europe & Asia with support from 1000 more scientific Societies and Publishes 700+ Open Access Journals which contains over 50000 eminent personalities, reputed scientists as editorial board members.

Open Access Journals gaining more Readers and Citations

700 Journals and 15,000,000 Readers Each Journal is getting 25,000+ Readers

This Readership is 10 times more when compared to other Subscription Journals (Source: Google Analytics)


Introduction: Good medical record keeping is at the forefront of medical practice. Not only do medical notes act as a learning tool, they are needed in medico-legal circumstances and more importantly, for patient safety and communication between multi-disciplinary team members. The General Medical Council wishes for clinicians to keep ‘good’ notes in a coherent, chronological and accurate order. Objective: The Royal College of Physicians (RCP) audit tool released in 2008 assesses 12 standards of medical notes, with which this audit has been conducted. The objective was to measure medical note keeping in accordance with published guidelines.

Method: A concurrent review of inpatient notes on a medical ward, Fairfield General Hospital (FGH) was undertaken with standards set at 100%. A questionnaire exploring attitudes to medical record keeping was also piloted.

Result: Standards measured increased over the 3 audit cycles with 3 of the indicators (writing a date, patient name and hospital number) reached 100%. The questionnaire showed 60% of the cohort had not read guidelines on note keeping and were dissatisfied with the standard of medical notes on their wards.

Conclusion: These results indicate medical note keeping has scope for improvement and auditing can improve standards. They also highlight a need for development in the way doctors are trained, with regards to medical note keeping

To read the full article Peer-reviewed Article PDF image | Peer-reviewed Full Article image

Author(s): Maiedha Raza


medical, note, keeping, records

Peer Reviewed Journals
Make the best use of Scientific Research and information from our 700 + peer reviewed, Open Access Journals
International Conferences 2017-18
Meet Inspiring Speakers and Experts at our 3000+ Global Annual Meetings

Contact Us

© 2008-2017 OMICS International - Open Access Publisher. Best viewed in Mozilla Firefox | Google Chrome | Above IE 7.0 version