Annals of Indian Academy of Neurology
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Year : 2013  |  Volume : 16  |  Issue : 4  |  Page : 627-630

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

1 Department of Neurology, Mater University Hospital, Dublin, Ireland
2 Department of Medicine, St. Michael's Hospital, Dublin, Ireland

Correspondence Address:
Shakya Bhattacharjee
95/B, Indra Biswas Road, Kolkata- 700 037, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0972-2327.120498

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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.

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