IMPROVING THE RECORDING OF THE CLINICAL-ASSESSMENT OF STROKE PATIENTSUSING A CLERKING PRO FORMA

In this study we examine whether the introduction of a clerking pro fo rma improves the completeness of the recording of the management of st roke patients and we review methodological issues important in this ty pe of audit. We prospectively identified 244 consecutive stroke patien ts before and after the introduction of the pro forma. Patient case no tes were traced and audited using a specifically designed form. Follow ing the introduction of the pro forma, there was a significant improve ment in the completeness of the recording of patient management; no ch ange was observed for those items not included in the pro forma, sugge sting a causal effect. We conclude that a stroke clerking pro forma im proves the completeness of the recording of the assessment of hospital ized stroke patients; this has implications for clinical practice and future audit and may be applicable to other common conditions. We emph asize that methodological problems associated with a case note audit m ust be addressed if it is to produce useful, comparative data.