Prospective audit of the quality of ENT emergency clinic notes before and after introduction of a computerized template

Abstract

This study evaluated the accuracy of notes in an ENT urgent referral clinic, based on a standard of note keeping established within the trust. The results initially failed to meet the set standard and a change of practice was initiated by introduction of a computerized template that allowed for easier and more accurate data entry. After re-evaluation, the notes were found to be accurate and to contain relevant demographic data in more than 90 per cent of cases.