F. AlHarmoodi^1,, H. Anuff¹, M. AlMatrooshi¹, M. AlSuwaidi¹, K. Kessler¹

Introduction: Clinical record keeping is an essential component of good professional practice and delivery of quality healthcare. Hence, documenting a proper history is crucial for patient care and can help with both medicolegal purposes and future research. Therefore, many projects have focused on improving this aspect of healthcare. This audit project aimed to evaluate the current practice at Al Ain Hospital, and its impact after education. Methods: We reviewed all admission notes between January 2019 and March 2019 for patients aged> 16 years who were admitted to Al Ain Hospital with acute appendicitis and focused on the documentation of “past surgical history” in the admission note. After educating the healthcare staff, a review of the admission notes from January 2020 to February 2020 was conducted to compare the results. Results: The initial collected data showed a deficiency of documentation. After presenting of the data and instruction of the health care workers, a re-auditing was obtained. The new data showed good improvement of the documentation between 16- 50% increase, however experienced physicians were still lacking. Conclusion: Proper documentation of patient’s medical record is important and essential to obtain correct management. Educating all healthcare workers regardless of their experience is one of the ways to improve documentation.

surgical history, medical record, electronic, documentation