{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,12,8]],"date-time":"2025-12-08T13:45:00Z","timestamp":1765201500218,"version":"3.46.0"},"reference-count":30,"publisher":"Springer Science and Business Media LLC","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2025,12,8]]},"DOI":"10.7759\/cureus.98706","type":"journal-article","created":{"date-parts":[[2025,12,8]],"date-time":"2025-12-08T13:43:02Z","timestamp":1765201382000},"source":"Crossref","is-referenced-by-count":0,"title":["A Standardised Clerking Proforma Improves the Perceived Satisfaction of Healthcare Professionals and Leads to Better Documentation"],"prefix":"10.7759","author":[{"given":"Ahamed T","family":"Mohideen","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Michael","family":"Foxall-Smith","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Matthew","family":"Arnaouti","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Katy","family":"Emslie","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Devender","family":"Mittapalli","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"297","reference":[{"key":"ref1","doi-asserted-by":"publisher","DOI":"10.7861\/clinmedicine.3-4-329","article-title":"Standards in medical record keeping","volume":"3","author":"Mann R","year":"2003","unstructured":"Mann R, Williams J. Standards in medical record keeping. Clin Med (Lond). 2003, 3:329-32. 10.7861\/clinmedicine.3-4-329","journal-title":"Clin Med (Lond)"},{"key":"ref2","doi-asserted-by":"publisher","DOI":"10.1136\/bmjqs.2009.038976","article-title":"Quality of patient record keeping: an indicator of the quality of care?","volume":"20","author":"Zegers M","year":"2011","unstructured":"Zegers M, de Bruijne MC, Spreeuwenberg P, Wagner C, Groenewegen PP, van der Wal G. Quality of patient record keeping: an indicator of the quality of care?. BMJ Qual Saf. 2011, 20:314-8. 10.1136\/bmjqs.2009.038976","journal-title":"BMJ Qual Saf"},{"key":"ref3","doi-asserted-by":"publisher","DOI":"10.1016\/j.jamcollsurg.2009.10.008","article-title":"Lack of emergency medical services documentation is associated with poor patient outcomes: a validation of audit filters for prehospital trauma care","volume":"210","author":"Laudermilch DJ","year":"2010","unstructured":"Laudermilch DJ, Schiff MA, Nathens AB, Rosengart MR. Lack of emergency medical services documentation is associated with poor patient outcomes: a validation of audit filters for prehospital trauma care. J Am Coll Surg. 2010, 210:220-7. 10.1016\/j.jamcollsurg.2009.10.008","journal-title":"J Am Coll Surg"},{"key":"ref4","unstructured":"NHS Resolution continues trend of resolving more cases without need for litigation. (2024). Accessed. 2025: https:\/\/resolution.nhs.uk\/2024\/07\/23\/nhs-resolution-continues-trend-of-resolving-more-cases-without-need-for-litigation\/."},{"key":"ref5","article-title":"Good Surgical Practice","year":"2014","unstructured":"Good Surgical Practice. The Royal College of Surgeons of England, London; 2014."},{"key":"ref6","article-title":"Standards for the Clinical Structure and Content of Patient Records","year":"2013","unstructured":"Standards for the Clinical Structure and Content of Patient Records. Royal College of Physicians, London; 2013."},{"key":"ref7","article-title":"Standards for the Structure and Content of Health and Care Records","year":"2018","unstructured":"Standards for the Structure and Content of Health and Care Records. Professional Record Standards Body, London; 2018."},{"key":"ref8","article-title":"Generic Medical Record Keeping Standards","year":"2015","unstructured":"Generic Medical Record Keeping Standards. Royal College of Physicians, London; 2015."},{"key":"ref9","article-title":"","year":"2014","unstructured":"London Quality Standards Self-Assessment 2013. NHS England, London; 2014. https.\/\/www.england.nhs.uk\/london\/wp-content\/uploads\/sites\/8\/2014\/05\/self-ass-pan-london-rep.pdf."},{"key":"ref10","doi-asserted-by":"publisher","DOI":"10.7861\/clinmedicine.1-4-327","article-title":"Medical admissions can be made easier, quicker and better by the use of a pre-printed Medical Admission Proforma","volume":"1","author":"Irtiza-Ali A","year":"2001","unstructured":"Irtiza-Ali A, Houghton CM, Raghuram A, O'Driscoll BR. Medical admissions can be made easier, quicker and better by the use of a pre-printed Medical Admission Proforma. Clin Med (Lond). 2001, 1:327. 10.7861\/clinmedicine.1-4-327","journal-title":"Clin Med (Lond)"},{"key":"ref11","doi-asserted-by":"publisher","DOI":"10.1136\/bmjquality.u203012.w1388","article-title":"How complete are our clerkings? A project aimed at improving the quality of medical records by using a standardised proforma","volume":"2","author":"Chow J","year":"2014","unstructured":"Chow J, Yvon C, Stanger T. How complete are our clerkings? A project aimed at improving the quality of medical records by using a standardised proforma. BMJ Qual Improv Rep. 2014, 2:u203012.w1388. 10.1136\/bmjquality.u203012.w1388","journal-title":"BMJ Qual Improv Rep"},{"key":"ref12","doi-asserted-by":"publisher","DOI":"10.7861\/clinmedicine.3-4-385","article-title":"Medical admission records can be improved by the use of a structured proforma","volume":"3","author":"O'Driscoll BR","year":"2003","unstructured":"O'Driscoll BR, Al-Nuaimi D. Medical admission records can be improved by the use of a structured proforma. Clin Med (Lond). 2003, 3:385-6. 10.7861\/clinmedicine.3-4-385","journal-title":"Clin Med (Lond)"},{"key":"ref13","doi-asserted-by":"publisher","DOI":"10.1016\/j.amsu.2017.05.005","article-title":"Completeness in clerking: the surgical admissions proforma","volume":"19","author":"Bhanot K","year":"2017","unstructured":"Bhanot K, Abdi J, Bamania P, Samuel M, Watfah J. Completeness in clerking: the surgical admissions proforma. Ann Med Surg (Lond). 2017, 19:1-6. 10.1016\/j.amsu.2017.05.005","journal-title":"Ann Med Surg (Lond)"},{"key":"ref14","doi-asserted-by":"publisher","DOI":"10.7861\/futurehosp.5-2-121","article-title":"Do medical admission pro formas improve the completeness of documentation? A multisite observational study","volume":"5","author":"Smallwood N","year":"2018","unstructured":"Smallwood N, Russell J, Forbes-Pyman R, Coates A. Do medical admission pro formas improve the completeness of documentation? A multisite observational study. Future Healthc J. 2018, 5:121-5. 10.7861\/futurehosp.5-2-121","journal-title":"Future Healthc J"},{"key":"ref15","doi-asserted-by":"crossref","DOI":"10.7196\/SAMJ.7673","article-title":"Tick-box admission forms improve the quality of documentation of surgical emergencies, but have limited impact on clinical behaviour","volume":"104","author":"Laing GL","year":"2014","unstructured":"Laing GL, Bruce JL, Clarke DL. Tick-box admission forms improve the quality of documentation of surgical emergencies, but have limited impact on clinical behaviour. S Afr Med J. 2014, 104:435-8.","journal-title":"S Afr Med J"},{"key":"ref16","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijsu.2013.06.323","article-title":"Improvement in clinical recording keeping following the introduction of an admission clerking proforma for acute general surgical patients","volume":"11","author":"Gupta S","year":"2013","unstructured":"Gupta S, Ratnasingham K, Bhargava V, et al.. Improvement in clinical recording keeping following the introduction of an admission clerking proforma for acute general surgical patients. Int J Surg. 2013, 11:647. 10.1016\/j.ijsu.2013.06.323","journal-title":"Int J Surg"},{"key":"ref17","doi-asserted-by":"publisher","DOI":"10.1016\/j.amsu.2015.01.004","article-title":"The surgical admissions proforma: does it make a difference?","volume":"4","author":"Ehsanullah J","year":"2015","unstructured":"Ehsanullah J, Ahmad U, Solanki K, Healy J, Kadoglou N. The surgical admissions proforma: does it make a difference?. Ann Med Surg (Lond). 2015, 4:53-7. 10.1016\/j.amsu.2015.01.004","journal-title":"Ann Med Surg (Lond)"},{"key":"ref18","doi-asserted-by":"publisher","DOI":"10.7861\/clinmedicine.7-4-328","article-title":"Medical records and record-keeping standards","volume":"7","author":"Carpenter I","year":"2007","unstructured":"Carpenter I, Ram MB, Croft GP, Williams JG. Medical records and record-keeping standards. Clin Med (Lond). 2007, 7:328-31. 10.7861\/clinmedicine.7-4-328","journal-title":"Clin Med (Lond)"},{"key":"ref19","unstructured":"SurveyMonkey. (2024). Accessed. 2025: https:\/\/www.surveymonkey.com\/."},{"key":"ref20","doi-asserted-by":"publisher","DOI":"10.1016\/j.jsurg.2008.12.002","article-title":"Medical malpractice matters: medical record M & Ms","volume":"66","author":"Lyons JM 3rd","year":"2009","unstructured":"Lyons JM 3rd, Martinez JA, O'Leary JP. Medical malpractice matters: medical record M & Ms. J Surg Educ. 2009, 66:113-7. 10.1016\/j.jsurg.2008.12.002","journal-title":"J Surg Educ"},{"key":"ref21","doi-asserted-by":"publisher","DOI":"10.1016\/s0196-0644(05)80796-6","article-title":"The use of structured, complaint-specific patient encounter forms in the emergency department","volume":"22","author":"Wrenn K","year":"1993","unstructured":"Wrenn K, Rodewald L, Lumb E, Slovis C. The use of structured, complaint-specific patient encounter forms in the emergency department. Ann Emerg Med. 1993, 22:805-12. 10.1016\/s0196-0644(05)80796-6","journal-title":"Ann Emerg Med"},{"key":"ref22","article-title":"Quality of the information collected during admission to a hospital geriatric service: importance of a structured medical record [Article in French]","volume":"27","author":"Belmin J","year":"1998","unstructured":"Belmin J, de la Fourni\u00e8re F, Bellot P, et al.. Quality of the information collected during admission to a hospital geriatric service: importance of a structured medical record [Article in French]. Presse Med. 1998, 27:1519-22.","journal-title":"Presse Med"},{"key":"ref23","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(97)08307-4","article-title":"Helping clinicians to find data and avoid delays","volume":"352","author":"Nygren E","year":"1998","unstructured":"Nygren E, Wyatt JC, Wright P. Helping clinicians to find data and avoid delays. Lancet. 1998, 352:1462-6. 10.1016\/S0140-6736(97)08307-4","journal-title":"Lancet"},{"key":"ref24","doi-asserted-by":"publisher","DOI":"10.1136\/jcp.2004.021691","article-title":"Unnecessary repeat requesting of tests: an audit in a government hospital immunology laboratory","volume":"58","author":"Kwok J","year":"2005","unstructured":"Kwok J, Jones B. Unnecessary repeat requesting of tests: an audit in a government hospital immunology laboratory. J Clin Pathol. 2005, 58:457-62. 10.1136\/jcp.2004.021691","journal-title":"J Clin Pathol"},{"key":"ref25","doi-asserted-by":"publisher","DOI":"10.1097\/pq9.0000000000000247","article-title":"Use of a pediatric admission booklet significantly improves the comprehensiveness of admission documentation: a quality improvement project","volume":"5","author":"Beverstock A","year":"2020","unstructured":"Beverstock A, Lewis C, Bruce D, Barnes J, Kelly A. Use of a pediatric admission booklet significantly improves the comprehensiveness of admission documentation: a quality improvement project. Pediatr Qual Saf. 2020, 5:e247. 10.1097\/pq9.0000000000000247","journal-title":"Pediatr Qual Saf"},{"key":"ref26","article-title":"Use of the CRABEL score for improving surgical case-note quality","volume":"87","author":"Ho MY","year":"2005","unstructured":"Ho MY, Anderson AR, Nijjar A, Thomas C, Goenka A, Hossain J, Curley PJ. Use of the CRABEL score for improving surgical case-note quality. Ann R Coll Surg Engl. 2005, 87:454-7.","journal-title":"Ann R Coll Surg Engl"},{"key":"ref27","doi-asserted-by":"publisher","DOI":"10.1308\/003588412x13171221499865","article-title":"The STAR score: a method for auditing clinical records","volume":"94","author":"Tuffaha H","year":"2012","unstructured":"Tuffaha H, Amer T, Jayia P, Bicknell C, Rajaretnam N, Ziprin P. The STAR score: a method for auditing clinical records. Ann R Coll Surg Engl. 2012, 94:235-9. 10.1308\/003588412x13171221499865","journal-title":"Ann R Coll Surg Engl"},{"key":"ref28","article-title":"A Paperless NHS: Electronic Health Records","author":"Parkin E","year":"2016","unstructured":"Parkin E. A Paperless NHS: Electronic Health Records. House of Commons Library, London; 2016."},{"key":"ref29","article-title":"Achieving a Digital NHS: Lessons for National Policy from the Acute Sector","author":"Castle-Clarke S","year":"2019","unstructured":"Castle-Clarke S, Hutchings R. Achieving a Digital NHS: Lessons for National Policy from the Acute Sector. Nuffield Trust, London; 2019."},{"key":"ref30","unstructured":"Abandoned NHS IT system has cost \u00a310bn so far. (2013). Accessed. 2025: https:\/\/www.theguardian.com\/society\/2013\/sep\/18\/nhs-records-system-10bn."}],"container-title":["Cureus"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.cureus.com\/articles\/439585-a-standardised-clerking-proforma-improves-the-perceived-satisfaction-of-healthcare-professionals-and-leads-to-better-documentation","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,12,8]],"date-time":"2025-12-08T13:43:04Z","timestamp":1765201384000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.cureus.com\/articles\/439585-a-standardised-clerking-proforma-improves-the-perceived-satisfaction-of-healthcare-professionals-and-leads-to-better-documentation"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,12,8]]},"references-count":30,"URL":"https:\/\/doi.org\/10.7759\/cureus.98706","relation":{},"ISSN":["2168-8184"],"issn-type":[{"value":"2168-8184","type":"print"}],"subject":[],"published":{"date-parts":[[2025,12,8]]}}}