To what extent do New Zealand osteopathic students meet the national requirements for clinical record keeping : an audit

Abstract

Keeping clinical records of patient interactions in the medical profession is a legal obligation for any practitioner. Each medical profession has their own guidelines and requirements for what needs to be written within each record, with importance being placed on maintaining good quality records due to the potential consequence of patient adverse events and legal retributions. In this study, 193 new patient clinical records from a two- year period were audited. The aim was to determine if osteopathic students were compliant with all relevant record keeping standards and requirements in New Zealand. This current study employed a new Modified Clinical Record Keeping Tool (M -RKAT), alongside an interpretation guideline for each of the 57 items within the tool. A numerical scoring system was applied (1-5) and two benchmarks for the records were set. One of a mandatory level of completion of 50%, and one of a satisfactory level of completion of 75% for all clinical records. Statistical Analyses was preformed using SPSS software to calculate descriptive statistics and test the data for normality. Whilst a one-way repeated ANOVA score was calculated to ascertain any change in record-keeping over time. Findings showed that over the 193 records, the M -RKAT mean score was 72.30% (SD 5.79) 95% CI (71.47, 73.12), which fell below the 75% benchmark of satisfaction for clinical record keeping. The level of quality for the student clinical records did not change over the two -year period. The study also found that 38 out of 57 items needed to be improved upon in terms of quality as all gained a score of 3 or below which fell below the standard for record keeping. This study provides evidence to support further research, encouraging a full audit process to be taken in the future to see if improvements can be made in student clinical record keeping following intervention.