A study on the standard of documentation of lumbar puncture in neurology department of a major Irish Teaching Hospital in Ireland

• Main Authors: Shakya Bhattacharjee, Gurpreet Kaur
• Format: Article
• Language: English
• Published: Wolters Kluwer Medknow Publications 2013-01-01
• Series: Annals of Indian Academy of Neurology
• Subjects: Consent; documentation; knowledge; lumbar; neurology; puncture
• Online Access: http://www.annalsofian.org/article.asp?issn=0972-2327;year=2013;volume=16;issue=4;spage=627;epage=630;aulast=Bhattacharjee
• ISSN: 0972-2327; 1998-3549

Objective: Poor documentation following lumbar puncture (LP) had always been a matter of concern. This study aimed to investigate the documentation pattern of neurology house officers, registrars (Regs), and specialist Regs following LP in a major teaching hospital. Materials and Methods: Total hundred patient records were examined in the light of a carefully designed proforma containing 15 important indicators of good-quality LP documentation. Result: Mean number of indicators overall documented by doctors was found to be 6.24 ± 3.0037. The mean number of indicators recorded by house officers was 5.11 ± 3.01 and Regs was 7.56 ± 3.28. A total of 33% LPs were performed without a documented consent. Only 36% performers documented the type and size of needle they used during the procedure. Only 46% documents revealed the strength and name of the local anesthetic used. Statistically significant difference between senior house officers and Regs in terms of numbers of indicators documented was noted. Conclusion : The documentation standard among neurology junior doctors remained poor.