Medical Note Quality Audit at the Vascular Surgical Unit Compared With the British Medical Journal (BMJ) Guidelines

Nicolette Busuttil; Kevin Cassar; Gordon Caruana Dingli; Matthew Joe Grima

doi:10.7759/cureus.50110

Medical Note Quality Audit at the Vascular Surgical Unit Compared With the British Medical Journal (BMJ) Guidelines

Cureus. 2023 Dec 7;15(12):e50110. doi: 10.7759/cureus.50110. eCollection 2023 Dec.

Authors

Nicolette Busuttil¹, Kevin Cassar^{2

3}, Gordon Caruana Dingli^{4

5}, Matthew Joe Grima^{2

6}

Affiliations

¹ Surgery, Mater Dei Hospital, Msida, MLT.
² Vascular Surgery, Mater Dei Hospital, Msida, MLT.
³ Vascular Surgery, University of Malta, Msida, MLT.
⁴ Breast Surgery, Mater Dei Hospital, Msida, MLT.
⁵ General Surgery, University of Malta, Msida, MLT.
⁶ Vascular Surgery, Uppsala University Hospital, Uppsala, SWE.

Abstract

Effective medical notes ensure comprehensive documentation in healthcare. This study evaluates medical note quality in the vascular unit at Mater Dei Hospital using British Medical Journal (BMJ) guidelines. Two cycles examine 17 parameters pre- and post-intervention, revealing notable, significant enhancements in patient identifiers, clinical summaries, examination, and planning. Future prospects involve digitizing note-taking, utilizing artificial intelligence (AI) for data organization, and simplifying entry methods. Implementation of electronic solutions is encouraged for improved accuracy, efficiency, and continuity of patient care.

Keywords: artificial intelligence in medical note writing; cardiothoracic & vascular surgery; electronic health records; history and physical note; medical note writing.