Setting the records straight: a study of hospital medical records undertaken by the Audit Commission
| DOI | https://doi.org/10.1108/eb027083 |
| Published date | 01 January 1996 |
| Pages | 13-32 |
| Date | 01 January 1996 |
| Author | LORRAINE NICHOLSON |
| Subject Matter | Information & knowledge management |
Setting the records straight:
a study of hospital medical
records undertaken by the Audit
Commission
LORRAINE NICHOLSON
1.
BACKGROUND TO THE STUDY
The Audit Commission is the statutory body which oversees the external
audit of local authorities and agencies within the National Health Service
in England and Wales. As part of its function the Commission reviews
the economy, efficiency and effectiveness of services provided by these
bodies by undertaking studies and audits of selected topics each year. The
study of medical records was one of these.
The Audit Commission study into medical records in England and Wales
commenced in 1993. This study was the first systematic review of medi-
cal records services since the creation of the National Health Service
(NHS) in 1948. The only other existing study into medical records cul-
minated in the Tunbridge Report in 1965 and this was concerned mainly
with the standardisation of documentation within the casenote.
This study was required as medical records services are expensive con-
suming between 2 and 4% of NHS costs equating to £200-£500 million
per annum. Medical records is a core function which, as a result of recent
reforms in the health service, enjoys an increasingly high profile. Litiga-
tion is on the increase in the UK and casenotes are key source documents
for hospitals and health professionals who have to defend negligence suits.
In looking for documentary evidence of progress in respect of record-
keeping the following quotations support the need for an in-depth study
of medical records:
Records Management Journal, vol. 6, no.
1,
April 1996, pp. 13-32
Records Management Journal vol. 6 no. 1
In 1863 Florence Nightingale observed
"In attempting to arrive at the truth, I have applied everywhere for infor-
mation, but in scarcely an instance have I been able to obtain hospital
records fit for any purpose of comparison. If they could be obtained they
would enable us to decide many other questions beside the one alluded
to.
They would show subscribers how their money was being spent, what
amount of good was really done with it, or whether the money was not
doing mischief rather than
good".
In 1993 the Health Service Commissioner stated that
' inadequacies in clinical as well as nursing records provide a recurring
theme in my reports. I still find examples of undated, untimed or illegible
entries and in some cases no entry at all about events that prove to be
significant All too often I find that the quality of care ... has been
damaged by failures to pass on or record important information'.
The National Confidential Enquiry into Peri-operative Deaths in 1993
reported that
'the loss or difficult retrieval of information and casenotes in hospital is
still a major problem for the Enquiry, and there are no signs of improve-
ment'.
2.
STUDY FINDINGS AND RECOMMENDATIONS
(N.B.
A full list of recommendations, chapter by chapter, is included as
an appendix).
In total 40 volunteer hospitals in England and Wales had their medical
records service reviewed. Of these 20 had in-depth studies undertaken with
the remaining 20 having a shortened version of the study. Reference vis-
its and short studies were undertaken in Scotland, Northern Ireland and
the Republic of Ireland.
2.1 Costs and activity
2.1.1 Cost data
Data was obtained about cost and activity in all of the 40 hospitals and
from analysis of this data the following facts emerged:
• By far the most significant cost of the medical records
service is the cost of staff which is in excess of 80% of
the total costs.
• Only 9 of the 40 sites incurred any costs for microfilm-
ing
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