Purpose – Up‐to‐date patient records are essential for safe and professional practice. They are an intrinsic component for providing adequate care and ensuring appropriate and systematic treatment plans. Furthermore, accurate and contemporaneous notes are essential for achieving professional standards from a medico‐legal perspective. The study's main aim was to investigate current record‐keeping practices by looking at whether out‐patient communication pathways to general practitioners, from letter dictation to insertion in the chart, were being satisfied. Design/methodology/approach – From current out‐patient attendees over six months, 100 charts were chosen randomly, and reviewed. A pro‐forma was used to collect data and this information was also checked against electronic records. Findings – Of the charts reviewed, 15 per cent had no letter. If one considers that one‐month is an acceptable time for letters to be inserted into the chart, then only 11 per cent satisfied this condition. Electronic data were also missing. Research limitations/implications – It is impossible to discern whether letters to GPs were dictated by the out‐patient doctor for each patient reviewed. Another limitation was that some multidisciplinary hospital teams have different out‐patient note‐keeping procedures, which makes some findings difficult to interpret. Practical implications – The review drew attention to current record‐keeping discrepancies, highlighting the need for medical record‐keeping procedures and polices to be put in place. Also brought to light was the importance of providing a workforce sufficient to meet the out‐patient team's administrative needs. An extended audit of other medical record‐keeping aspects should be carried out to determine whether problems occur in other areas. Originality/value – The study highlights the importance of establishing agreed policies and procedures for out‐patient record keeping and the need to have a checking mechanism to identify system weaknesses.
International Journal of Health Care Quality Assurance – Emerald Publishing
Published: Sep 7, 2010
Keywords: Auditing; Outpatients; Quality standards; Communication; Ireland
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