P29
FACULTY OF OCCUPATIONAL MEDICINE ELECTRONIC NOTES AUDIT
R. Hughes, K. McDowall, E. Murphy
Newcastle Occupational Health Service, Newcastle upon Tyne, UK
Background:
The Newcastle upon Tyne Hospitals NHS Foundation Trust Occupational Health Service (OHS) switched from using COHORT software to OPAS G2 software for the purpose of electronic note keeping in July 2023. A rolling audit is performed every 6-12 months to determine if Safe Effective Quality Occupational Health Service (SEQOHS) standards for electronic note keeping are being adhered to.
Aims:
To determine if electronic notes meet the required standards set by SEQOHS.
Methods:
40 management referral assessment notes from the period 10/10/2023 to 24/10/2023 were reviewed. Audit questions were taken from the Faculty of Occupational Medicine National Audit section on electronic records, with 12 questions used. Data was compared to that collected in the previous audit from April 2023.
Results:
Newcastle OHS adheres to approved guidelines for electronic note keeping in the majority of assessed fields. The audit demonstrated that abbreviations or symbols were used in all the notes reviewed (40/40). There were 11 cases where the clinician reviewing the notes did not understand all the abbreviations used as opposed to 0 cases in the March 2023 audit.
Job title was recorded in all cases (40/40) and the record showed that the clinician had provided or offered to provide a copy of the report in all cases (40/40) which was an improvement compared with March 2023 (34/36 and 29/36 respectively).
Conclusions:
Our OHS department adheres to approved guidelines for electronic note keeping in the majority of assessed fields and the interventions suggested following the March 2023 audit have been effective.
References:
http://www.seqohs.org/CMS/Page.aspx?PageId=1160
http://www.fom.ac.uk/wp-content/uploads/HWDU-record-keeping-2012.pdf
