The STAR score: a method for auditing clinical records

INTRODUCTION Adequate medical note keeping is critical in delivering high quality healthcare. However, there are few robust tools available for the auditing of notes. The aim of this paper was to describe the design, validation and implementation of a novel scoring tool to objectively assess surgical notes. METHODS An initial ‘path finding’ study was performed to evaluate the quality of note keeping using the CRABEL scoring tool. The findings prompted the development of the Surgical Tool for Auditing Records (STAR) as an alternative. STAR was validated using inter-rater reliability analysis. An audit cycle of surgical notes using STAR was performed. The results were analysed and a structured form for the completion of surgical notes was introduced to see if the quality improved in the next audit cycle using STAR. An education exercise was conducted and all participants said the exercise would change their practice, with 25% implementing major changes. RESULTS Statistical analysis of STAR showed that it is reliable (Cronbach’s a = 0.959). On completing the audit cycle, there was an overall increase in the STAR score from 83.344% to 97.675% (p<0.001) with significant improvements in the documentation of the initial clerking from 59.0% to 96.5% (p<0.001) and subsequent entries from 78.4% to 96.1% (p<0.001). CONCLUSIONS The authors believe in the value of STAR as an effective, reliable and reproducible tool. Coupled with the application of structured forms to note keeping, it can significantly improve the quality of surgical documentation and can be implemented universally

Corticosteroid treatment in the management of idiopathic granulomatous mastitis to avoid unnecessary surgery

Idiopathic granulomatous mastitis (IGM) is a rare benign inflammatory disease of the breast. It can mimic breast carcinoma clinically and radiologically, and usually affects females of childbearing age. There is no commonly accepted optimal treatment for IGM. In this study, we present the clinical and histopathological features and outcomes of the therapeutic management of IGM, as well as the clinical course of the disease when patients were treated with oral corticosteroids