Background: Rheumatoid arthritis is a chronic disease. A patient's disease activity at prior clinic visits informs decisions regarding future treatment. Hence accurate documentation at outpatient attendances is vital. This has led to advocates for computerized database systems to ensure accurate recording of important information.

Objectives: We performed a retrospective chart review of 102 outpatients with rheumatoid arthritis to assess for accuracy of documentation of important clinical information.

Methods: Our centre is a 650 bed academic teaching hospital. The outpatient clinic is staffed by doctors with a wide range of competencies, ranging from consultant rheumatologists to junior house staff undertaking short rotations as part of their GIM training. We assessed the most recent clinic visit between the 1st January 2008 and the 1st January 2009 for accuracy of documentation. This was divided into 6 aspects – clinical symptoms, clinical signs, extra-articular manifestations, medications, radiology and laboratory investigations. Clinical symptoms assessed were early morning stiffness, pain, swelling and loss of function. Tender and swollen joint counts and synovitis comprised clinical signs assessed. Radiological documentation comprised the date and findings of last radiographs and the due date of the next radiograph. Laboratory investigations assessed were FBC, U+E, LFT's, ESR, CRP, RF and CCP. The recording of the presence or absence of extra-articular manifestations and of current medications were also assessed.

Results: 102 patients were assessed. Clinical signs and symptoms were documented in 33% and 36% of patients respectively. Extra-articular manifestions were recorded in 8% of patients. Current medications were documented in 90% of patients. Radiological findings were documented in 18.3% and laboratory investigations in 32.4% of patients. These results give an overall completeness of documentation of 36.46%

Conclusion: Documentation of rheumatoid arthritis patient's outpatient visits has been shown to be poor in our study. This provides further support for the developing role of computerized databases in patient care in rheumatology.

Disclosure of Interest: None declared