Clinical & Experimental Cardiology
Open Access

The ECG on the ward: Cultivating better note making

6^th International Conference on Clinical & Experimental Cardiology

November 30-December 02, 2015 San Antonio, USA

Sarah Pywell and Will Niven

Homerton Univeristy Hospital, England

Posters-Accepted Abstracts: J Clin Exp Cardiolog

Abstract :

This is a Quality Improvement Project (QIP) that has been performed as a result of the perceived lack of documentation that appears on ECG�s performed on the ward. 17 ECG�s were analysed at random. They were checked to see if there was an assessment of what the ECG showed, an action planned based on this and whether or not the clinician was identifiable. A clinician was identifiable in 17%, an assessment in 41% and an action plan in 35%. An ECG stamp in table format combined with an effective education strategy could help to overcome this lack of documentation. An ECG stamp in table format combined with an effective education strategy could help to overcome this lack of documentation. This QIP aims to establish current levels of ECG documentation and depending upon the outcome, to improve the quality of this documentation. There is no audit standard at present, but there are precedents in this field and the author has carried out similar multi-cycle audits in 2 other hospitals. Given that documentation is so important, the analysing clinician, the time seen, the assessment and an action plan should be written on 100% of ECGs and consideration of introducing a standard. This audit confirms that the quality of ECG notation is poor at the moment. Whilst an assessment of the ECG was present in 41%, a clear written instruction of how to proceed was not. This has clear implications in the early detection of ischaemic chest pain. If this is not clearly written, there is no record of it having been requested and consequently no defence should there be a critical incident or at worst a medico-legal enquiry. Equally, if the time that the ECG was viewed was not recorded, then information gathering is reliant on memory or here say which has, of course, never been rated as particularly reliable. The culture of �signature signing� is also problematic.

Biography :

Email: s.pywell@nhs.net