Compliance with RCP standards in medical documentation: a retrospective audit at UHW

Background: Effective medical documentation is essential for patient safety, quality of care, and compliance with information governance. This study investigates whether clinicians at University Hospital Wales (UHW) adhere to Royal College of Physicians (RCP) standards in medical documentation. Methods: A retrospective audit was conducted of the medical records of 200 inpatients seen during morning ward rounds in wards A1N and A1S from 10 October 2024 to 9 November 2024. The audit analysed compliance with key RCP recommendations, excluding new patients whose notes were recorded on the same day. Results: Compliance rates for key documentation criteria were recorded as follows: patient identification was present in 88% of cases, whereas chronological ordering of entries was observed in 59%. Timestamping was present in only 55% of cases, and location information was recorded in just 16%. Although date recording achieved a high compliance rate of 99.5%, entries including both the name and designation of the clinician were noted in only 48% of records. Furthermore, only 42% of records included advanced decisions regarding treatment refusals and CPR. Conclusions: The audit highlights significant deficiencies in medical documentation practices at UHW, indicating a clear need for improvement, particularly in time and location recording and ensuring that all entries include the responsible clinician’s details. To enhance compliance with General Medical Council (GMC) and RCP standards, we recommend implementing educational initiatives for clinical staff, increasing awareness through departmental forums and reinforcing documentation training during grand rounds. Continuous monitoring and adherence to best practices will be vital in fostering a culture of accountability and improving overall patient care.

Abstract licence: CC BY-NC-ND

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