Aims To assess the quality and availability of data recorded within clinic letters regarding diagnosis, classification, investigation and management of Cerebral Palsy (CP).
Methods A retrospective review of case notes on the most recently reviewed (n=50) patients within community paediatric catchment area with a diagnosis of CP, assessing quality of data recorded in the last clinic letter.
Results Mean age at first referral was 2.06 years. 64% had Spastic CP, with 74% having bilateral symptoms. GMFCS score was recorded in 54% and MACS score in 0%. Specific areas of management varied dramatically: input recorded physiotherapy 70%, psychological 6%.
30% of letters noted cognitive skills, 34% visual assessment, 12% hearing status, 36% presence of epilepsy, 32% MRI findings, 14% hip-x-ray, 22% SALT involvement and 32% OT involvement.
Conclusion The data suggests that there is currently poor written communication of functionality and involvement of multiple professional groups in this sample of children with CP, although diagnostic elements are better recorded.
The information required may be elsewhere not readily apparent within the notes. Therefore it would not be safe to assume that absence of details signifies lack of professional involvement or normal functionality.
This information is critical to understanding patient needs, especially since patients may be seen by different healthcare professionals with limited handover. Lack of such clear communication makes it difficult to audit sub-groups of patients and identify the quality of care being provided.
Subsequent to this audit outcome documentation template for clinic reviews for children with CP has been developed.