Background and Aims It is believed that the medical reports submitted to the Education Department are wordy and repetitive. The aims of the audit were to create clear and concise reports for the Education as a part of the special needs assessment and to test the above hypothesis.
Methods It is a retrospective qualitative analysis of the medical reports submitted to the Education department by a busy Community Paediatrics department of a District General hospital. 46 reports which were submitted to the Education from January 2011 to April 2011 were analysed through a standardised audit questionnaire.
Results Of all 46 reports, 100% had parental views expressed, 98% had no repetition, 86% had some documentation about the behaviour, in 85% the summary was clear and concise with appropriate recommendations, 82% had documentation about the hearing and 80% had documentation about the vision and developmental milestones. On the other hand only 56% had some documentation about the medications, 47% had a problem list, 28% had documentation of learning ability and 8% had documentation about strengths.
Conclusions The hypothesis that the medical reports are wordy and repetitive is wrong however there should be clear headings for problem list, medications, vision, hearing and developmental milestones. It was found that the existing template for the medical reports was not followed. As a result of this audit, a new template for the medical reports was developed to be used by the Community Paediatricians in an attempt to provide clear and concise reports for the Education Department.