Improving the Recording of the Clinical Assessment of Stroke Patients using a Clerking Pro Forma

摘要

In this study we examine whether the introduction of a clerking pro forma improves the completeness of the recording of the management of stroke patients and we review methodological issues important in this type of audit. We prospectively identified 244 consecutive stroke patients before and after the introduction of the pro forma. Patient case notes were traced and audited using a specifically designed form. Following the introduction of the pro forma, there was a significant improvement in the completeness of the recording of patient management; no change was observed for those items not included in the pro forma, suggesting a causal effect. We conclude that a stroke clerking pro forma improves the completeness of the recording of the assessment of hospitalized stroke patients; this has implications for clinical practice and future audit and may be applicable to other common conditions. We emphasize that methodological problems associated with a case note audit must be addressed if it is to produce useful, comparative data.