The STAR score: a method for auditing clinical records
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Author(s)
Type
Journal Article
Abstract
INTRODUCTION
Adequate 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.
METHODS
An 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.
RESULTS
Statistical 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).
CONCLUSIONS
The 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.
Adequate 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.
METHODS
An 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.
RESULTS
Statistical 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).
CONCLUSIONS
The 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.
Date Issued
2015-03-11
Date Acceptance
2015-03-11
Citation
Annals of the Royal College of Surgeons of England, 2015, 94 (4), pp.235-239
ISSN
1478-7083
Publisher
Royal College of Surgeons of England
Start Page
235
End Page
239
Journal / Book Title
Annals of the Royal College of Surgeons of England
Volume
94
Issue
4
Copyright Statement
This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Subjects
Science & Technology
Life Sciences & Biomedicine
Surgery
SURGERY
Note keeping
CRABEL
Audit
Structured admission forms
Scoring tool
MEDICAL-RECORDS
CRABEL SCORE
ADMISSION PROFORMA
STANDARDS
QUALITY
Documentation
Humans
Medical Audit
Medical Records
Observer Variation
Patient Discharge
Pilot Projects
Quality Control
Quality of Health Care
Surgical Procedures, Operative
1103 Clinical Sciences
Publication Status
Published