Abstract
At present, doctors in some tertiary pediatric hospitals across the United Kingdom record admission on blank continuation sheets rather than using a specific admission document. Previous evidence from adult medicine shows that using admission booklets to prompt the admitting doctor improves the thoroughness of admission documentation, but no work has evaluated this in pediatrics. METHODS: Documentation standards for pediatric admissions were created using national standards. We performed a baseline audit of admissions documented on blank continuation sheets. We included 120 patient admissions across pediatric medicine, pediatric surgery, and pediatric orthopedics (40 from each specialty). We introduced an admission booklet for each specialty, which contained prompts for documenting each aspect of the medical history. We then repeated the audit of 120 additional admissions documented on these booklets. RESULTS: On average, across all 3 specialties, there was a 33% increase in the inclusion of items in the documented history after the introduction of an admission booklet. In particular, documentation of medication history improved from 46% to 99%, and documentation of allergies improved from 47% to 93%. These improvements were statistically significant. CONCLUSION: We recommend the use of a pediatric admission booklet as a simple and effective way to improve medical record documentation. The use of these booklets was associated with an increase in the thoroughness of the documentation. As NHS hospitals transition to electronic medical records, they should make use of admission templates that retain the advantages of these paper booklets.