The STAR score: a method for auditing clinical records

Abstract

INTRODUCTIONAdequate medical note keeping is critical in delivering high quality healthcare. However, there are few robust tools available for the auditing of notes. The aim of this paper was to describe the design, validation and implementation of a novel scoring tool to objectively assess surgical notes.METHODSAn initial ‘path finding’ study was performed to evaluate the quality of note keeping using the CRABEL scoring tool. The findings prompted the development of the Surgical Tool for Auditing Records (STAR) as an alternative. STAR was validated using inter-rater reliability analysis. An audit cycle of surgical notes using STAR was performed. The results were analysed and a structured form for the completion of surgical notes was introduced to see if the quality improved in the next audit cycle using STAR. An education exercise was conducted and all participants said the exercise would change their practice, with 25% implementing major changes.RESULTSStatistical analysis of STAR showed that it is reliable (Cronbach’s a = 0.959). On completing the audit cycle, there was an overall increase in the STAR score from 83.344% to 97.675% (p<0.001) with significant improvements in the documentation of the initial clerking from 59.0% to 96.5% (p<0.001) and subsequent entries from 78.4% to 96.1% (p<0.001).CONCLUSIONSThe authors believe in the value of STAR as an effective, reliable and reproducible tool. Coupled with the application of structured forms to note keeping, it can significantly improve the quality of surgical documentation and can be implemented universally.

The TONK score: a tool for assessing quality in trauma and orthopaedic note-keeping

“…Tuffaha et al produced a similar scoring system based on the CRABEL score [ 13 ]. This scoring system (STAR score) also takes into account the quality of the consenting process and operation note.…”

The use of a pro forma to improve quality in clerking vascular surgery patients

“…This review showed that the use of a pro forma improves the quality of clerking documentation in elective surgical patients, and that standardisation of the medical record improved the quality of patient care. [6][7][8][9][10][11][12][13][14][15] Evidence is presented across the audits that the use of a pro forma leads to significantly improved documentation for surgical patients, in areas such as previous medical history and medication history. [7,12,13,15] It has also been shown to significantly improve the completion of VTE assessment.…”

Meeting National Safety and Quality Health Service Standards – The Role of the Point-of-Care (POC) Audit Application

“…So for example in performing falls risk assessments, or in reducing harder end points like hospital acquired pressure ulcers. An example of such an evaluation is the previously quoted work by Tuffaha et al [12].…”

“…Historically, many clinical audit [10], [11] processes-designed to collect information about an organizations or individuals compliance with clinical quality standards (eg -care measures to prevent pressure ulcers)-have been centered around primary data collection on paper-based structured, or unstructured, assessment tools. An example is the Surgical Tool for Auditing records (STAR), used for auditing clinical records in the UK [12].…”