Methods of improving the quality of record keeping in Occupational Health

Introduction
Included in basic Nursing Training are several aspects of recordkeeping including the importance of accurate legible records and legal clinical notes, etc. In every post basic nursing training modules on record keeping are included. Poor record keeping is a major problem in all sectors of nursing. In a study done by Dr Marieke Zegers, Netherlands Institute for Health Service Research it was found that there is a definite relation between poor quality of information in patient records and poor quality care. A good medical record provides an idea of the plan and treatment of a patient and is a way of communication between several members of the multidisciplinary team. Standardized medical documentation often helps to give guidance to the medical and occupational health staff. Improvement in completing medical records should be a continuous goal in all medical services.

Methods
Ongoing training and development should be done for existing and new staff. Different types of training were used during this study. Standardized documents and processes were used with clearly defined instructions. New and existing staff was trained on the job. Special in-house training days for training staff on specific topics was arranged. Regular scheduled training sessions were arranged to promote clear communication and build good staff interaction. Training through memo’s via e-mail and in staff communication circulated was also occurred. One to one training of staff using existing documents and records to show the shortcomings and problems in the recordkeeping also occurred.

Results
A descriptive analysis of data will be provided. At the time this abstract was submitted the results were not available.

Discussion
The importance of good quality recordkeeping should be emphasized to all occupational health staff. By keeping good medical records the nursing professional minimizes the medico-legal aspects and increase health care.