New check on health records

A FURTHER audit will look at ways of improving the quality of health records. A previous review found that the hospital's medical records were below quality service standards. It found that important information such as the treating consultant, discharge diagnosis or follow-up arrangements had often been omitted.

Parts of some patients' records were held at 34 separate health services locations.

The findings of the audit will form a baseline for future improvements and periodic external reviews.

'Clinical governance is about ensuring high standards of clinical care and one way we can demonstrate that is through having high-quality records,' said director of public health Dr David Jeffs.

'There were instances in our records where people felt important information was missing, but we are keen to see why it was not there and how to ensure we improve.'

A health records committee will be relaunched with adequate clinician involvement.

Records will be seen as an intrinsic part of health-care information and clinical governance and the records sections at the Princess Elizabeth Hospital, Castel and King Edward Hospitals integrated.

'At one time it was just a health record, but we feel it fulfils quite a number of other functions,' said Dr Jeffs.

'If things do go wrong we have to ensure we have a record so we can go back and see how to prevent it happening again.

'We also require it for planning purposes and for departmental information.'

He said that there was also a need to consolidate information.

'If a patient has been seen at the King Edward Hospital after falling over, it is silly to have one record there and another at the PEH. When a record is called up, it is very important that it says where other information is.'

He said that the plan was not suddenly to bring all the information into one place, because of the lack of storage, but to ensure electronic tagging to show that other health records existed and, over time, a consolidation of the various paper records.

Dr Jeffs said that, for the audit, patient details were anonymised so people could be reassured that confidentiality could not be compromised.

The department has committed to an electronic patient record within three to five years.