Aims (1) To determine the adherence to the National Institute for Health and Clinical Excellence (NICE) feverish illness guideline between a cohort of established and new-starting junior doctors in a paediatric emergency department. (2) To determine the effectiveness of single case note review as a method of auditing junior doctors adherence to the NICE feverish illness guideline.

Methods Structured case note review of junior doctors' management of children presenting with a fever or reported fever in July and August 2009. A non-randomised selection of case notes were chosen with doctors given anonymised codes to enable repeated performance to be measured.

Results 160 notes were reviewed in July and 133 notes in August. 21 contained either illegible or insufficient evidence for complete data analysis. (1) Safety net advice documented in those discharged from the emergency department fell from 70.9% (56/79) in July to 55.9% (33/59) in August. The percentage of children admitted in August was relatively higher (40.6% (65/160) vs 51.1% (68/133)). Admissions of children with only green signs (12 vs 9) and discharge of those with red signs (1 vs 1) were similar between July and August. (2) Individual doctors showed variation in their documentation. The paucity of red light patients made it difficult to define guideline non-adherence. A review of five case notes per doctors would provide relative consistency in terms of overall assessment.

Conclusions Providing safety net advice is a key message of the NICE feverish illness guideline. It is important induction processes emphasise this and that emergency departments audit effectively to ensure continued adherence.