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A study on the standard of documentation of lumbar puncture in neurology department of a major Irish Teaching Hospital in Ireland
oleh: Shakya Bhattacharjee, Gurpreet Kaur
Format: | Article |
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Diterbitkan: | Wolters Kluwer Medknow Publications 2013-01-01 |
Deskripsi
Objective: Poor documentation following lumbar puncture (LP) had always been a matter of concern. This study aimed to investigate the documentation pattern of neurology house officers, registrars (Regs), and specialist Regs following LP in a major teaching hospital. Materials and Methods: Total hundred patient records were examined in the light of a carefully designed proforma containing 15 important indicators of good-quality LP documentation. Result: Mean number of indicators overall documented by doctors was found to be 6.24 ± 3.0037. The mean number of indicators recorded by house officers was 5.11 ± 3.01 and Regs was 7.56 ± 3.28. A total of 33% LPs were performed without a documented consent. Only 36% performers documented the type and size of needle they used during the procedure. Only 46% documents revealed the strength and name of the local anesthetic used. Statistically significant difference between senior house officers and Regs in terms of numbers of indicators documented was noted. Conclusion : The documentation standard among neurology junior doctors remained poor.