{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,12,15]],"date-time":"2025-12-15T14:02:05Z","timestamp":1765807325121,"version":"3.48.0"},"reference-count":26,"publisher":"CSIRO Publishing","issue":"6","license":[{"start":{"date-parts":[[2025,5,29]],"date-time":"2025-05-29T00:00:00Z","timestamp":1748476800000},"content-version":"vor","delay-in-days":3388,"URL":"https:\/\/doi.org\/10.1071\/journalslicense"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2016,11,30]]},"abstract":"\n Objective<\/jats:title>\n The medical record is critical for documentation and communication between healthcare professionals. The aim of the present study was to evaluate important aspects of the orthopaedic medical record and system performance to determine whether any deficiencies exist in these areas.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n Review of 200 medical records of surgically treated traumatic lower limb injury patients was undertaken. The operative report, discharge summary and first and second outpatient reviews were evaluated.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n In all cases, an operative report was completed by a senior surgeon. Weight-bearing status was adequately documented in 91% of reports. Discharge summaries were completed for 82.5% of admissions, with 87.3% of these having instructions reflective of those in the operative report. Of first and second outpatient reviews, 69% and 73%, respectively, occurred within 1 week of the requested time. Previously documented management plans were changed in 30% of reviews. At 6-months post-operatively, 42% of patients had been reviewed by a member of their operating team.<\/jats:p>\n <\/jats:sec>\n \n Discussion<\/jats:title>\n Orthopaedic medical record documentation remains an area for improvement. In addition, hospital out-patient systems perform suboptimally and may affect patient outcomes.<\/jats:p>\n <\/jats:sec>\n \n What is known about the topic?<\/jats:title>\n Medical records are an essential tool in modern medical practice. Despite the importance of comprehensive documentation in the medical record, numerous examples of poor documentation have been demonstrated, including substandard documentation during consultant ward rounds by junior doctors leading to a breakdown in healthcare professional communication and potential patient mismanagement. Further inadequacies of medical record documentation have been demonstrated in surgical discharge notes, with complete and correct documentation reported to be as low as 65%.<\/jats:p>\n <\/jats:sec>\n \n What does this paper add?<\/jats:title>\n Standards of patient care should be constantly monitored and deficiencies identified in order to implement a remedy and close the quality loop. The present study has highlighted that the standard of orthopaedic trauma medical record keeping at an Australian Level 1 trauma centre is below what is expected and several key areas of documentation require improvement. This paper further evaluates the system performance of the out-patient system, an area where, to the authors knowledge, there is no previous work published. The findings show that the performance was below what is expected for surgical review, with many patients failing to be reviewed by their operating surgeon.<\/jats:p>\n <\/jats:sec>\n \n What are the implications for practitioners?<\/jats:title>\n The present study shows that there is a poor level of documentation and a standard of out-patient review below what is expected. The implications of these findings will be to highlight current deficiencies to practitioners and promote change in current practice to improve the quality of medical record documentation among medical staff. Further, the findings of poor system performance will promote change in the current system of delivering out-patient care to patients.<\/jats:p>\n <\/jats:sec>","DOI":"10.1071\/ah15160","type":"journal-article","created":{"date-parts":[[2016,2,17]],"date-time":"2016-02-17T17:20:45Z","timestamp":1455729645000},"page":"619-624","source":"Crossref","is-referenced-by-count":3,"title":["Medical record keeping and system performance in orthopaedic trauma patients"],"prefix":"10.1071","volume":"40","author":[{"given":"Filip","family":"Cosic","sequence":"first","affiliation":[{"name":"ADepartment of Orthopaedic Surgery, The Alfred, P.O. Box 315, Prahran, Vic. 3181, Australia. Email: ere@bigpond.net.au"},{"name":"DCorresponding author. Email: ftcos1@student.monash.edu"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lara","family":"Kimmel","sequence":"additional","affiliation":[{"name":"BDepartment of Physiotherapy, The Alfred, P.O. Box 315, Prahran, Vic. 3181, Australia. Email: l.kimmel@alfred.org.au"},{"name":"CDepartment of Epidemiology and Preventive Medicine, Monash University, Vic. 3004, Australia."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Elton","family":"Edwards","sequence":"additional","affiliation":[{"name":"ADepartment of Orthopaedic Surgery, The Alfred, P.O. Box 315, Prahran, Vic. 3181, Australia. Email: ere@bigpond.net.au"},{"name":"CDepartment of Epidemiology and Preventive Medicine, Monash University, Vic. 3004, Australia."}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"67","published-online":{"date-parts":[[2016,2,18]]},"reference":[{"key":"2025121501204002400_R1","doi-asserted-by":"publisher","first-page":"384","DOI":"10.4103\/0970-1591.56208","article-title":"Medical records and issues in negligence.","volume":"25","author":"Thomas","year":"2009","journal-title":"Indian J Urol"},{"key":"2025121501204002400_R2","first-page":"40","article-title":"Risk management: role of the medical record department.","volume":"12","author":"Feather","year":"1991","journal-title":"Top Health Rec Manage"},{"key":"2025121501204002400_R3","doi-asserted-by":"publisher","first-page":"309","DOI":"10.1046\/j.1365-2168.2001.01666.x","article-title":"Standards of documentation of the surgeon\u2013patient consultation in current surgical practice.","volume":"88","author":"Fernando","year":"2001","journal-title":"Br J Surg"},{"key":"2025121501204002400_R4","doi-asserted-by":"publisher","DOI":"10.1136\/bmjquality.u201042.w688","article-title":"Post-acute surgical ward round proforma improves documentation.","volume":"2","author":"Al-Mahrouqi","year":"2013","journal-title":"BMJ Qual Improv Rep"},{"key":"2025121501204002400_R5","first-page":"7","article-title":"Inadequacies of hospital medical records.","volume":"75","author":"Patel","year":"1993","journal-title":"Ann R Coll Surg Engl"},{"key":"2025121501204002400_R6","doi-asserted-by":"publisher","first-page":"60","DOI":"10.1177\/1062860612447856","article-title":"Diagnostic errors in orthopedic surgery: evaluation of resident documentation of neurovascular examinations for orthopedic trauma patients.","volume":"28","author":"Tan","year":"2013","journal-title":"Am J Med Qual"},{"key":"2025121501204002400_R7","doi-asserted-by":"publisher","first-page":"346","DOI":"10.2106\/JBJS.D.02007","article-title":"Documentation of acute compartment syndrome at an academic health-care center.","volume":"87","author":"Cascio","year":"2005","journal-title":"J Bone Joint Surg Am"},{"key":"2025121501204002400_R8","doi-asserted-by":"publisher","first-page":"218","DOI":"10.1007\/BF02600538","article-title":"Use of an outpatient medical record audit to achieve educational objectives: changes in residents\u2019 performances over six years.","volume":"5","author":"Kern","year":"1990","journal-title":"J Gen Intern Med"},{"key":"2025121501204002400_R9"},{"key":"2025121501204002400_R10","doi-asserted-by":"publisher","first-page":"941","DOI":"10.1245\/ASO.2004.12.045","article-title":"The computer synoptic operative report: a leap forward in the science of surgery.","volume":"11","author":"Edhemovic","year":"2004","journal-title":"Ann Surg Oncol"},{"key":"2025121501204002400_R11","doi-asserted-by":"publisher","first-page":"578","DOI":"10.1111\/j.1365-2753.2010.01626.x","article-title":"Improving the quality of general surgical operation notes in accordance with the Royal College of Surgeons guidelines: a prospective completed audit loop study.","volume":"18","author":"Singh","year":"2012","journal-title":"J Eval Clin Pract"},{"key":"2025121501204002400_R12","doi-asserted-by":"publisher","first-page":"677","DOI":"10.1111\/j.1742-1241.2007.01292.x","article-title":"The quality of operative note taking: an audit using the Royal College of Surgeons Guidelines as the gold standard.","volume":"61","author":"Shayah","year":"2007","journal-title":"Int J Clin Pract"},{"key":"2025121501204002400_R13","first-page":"8","article-title":"An audit of the quality of operation notes in two district general hospitals. 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