Over a million patients seen without records

22 May 2008

A poll of NHS acute trusts indicates over 1.2m outpatients in England are seen each year without the clinician having access to a patient's records.

Health Service Journal magazine surveyed 49 NHS trusts and found that in the last year, around 54,000 outpatient appointments took place without the use of medical records.

Of the 49 trusts, 5% admitted having notes missing, and in total, an average 2.6% of outpatient records were missing.

The magazine says that if the figures were projected nationally, approximately 1.2m outpatients in England would be seen without their notes every year.

A Patients Association spokesperson told E-Health Insider: “This investigation reveals that patient safety is at risk. The solution is for patients to keep their own records. There has always been a cavalier attitude to records. Other businesses would not get away with this.

“If you haven't got the records you haven't got a true history of the patient sitting in front of you. You don't know who you are treating or what is wrong with them.”

City Hospitals Sunderland NHS Foundation Trust had the highest rate of notes unavailable, with 19% of outpatient appointments conducted without records.

A spokesman for the trust said the situation was improving and they were recruiting a records manager to address the issue.

Professor John Williams, from the Royal College of Physicians said not having the full patient record at the time of the appointment was dangerous.

“There may be issues about the patient you are not aware of. It becomes a self perpetuating and escalating problem because once the notes go missing you end up creating multiple duplicate records.”

A DH spokesperson told EHI: “The NHS seeks to ensure that everyone has the best level of care possible. The NHS Care Records Service is already helping NHS staff to deliver better, safer, care and we know that part of this is ensuring patient records are kept private, secure and confidential.

“There may of course be some perfectly legitimate reasons that records are not present, as a result of a considered clinical judgement where a patient is well known to the doctor, and where their condition not complex, and stable.”

Reader's Comments

Instituions and Individuals

22 May 08 11:55

Just to be precise about the words here. These are people seen without the HOSPITAL's patient record. Many more people receive care whilst functionally recordless because the particular institution's record, even if it makes it to the clinic, does not contain the pertinent information. Why should it if the relevant events took place elsewhere, and possibly not in a 'formal' health care institution at all? Whilst we persist in formulating the task of supporting an individual's health and care in entirely institution-centric language and concepts, we have little hope of understanding, let alone tackling the problem. We conflate, or perhaps even equate, the task of running the hospital with 'running Mrs Smith'. They are both important and need to work together, but they are different. The former is often inefficient. The latter is profoundly broken. A Nowlan

Running Mrs Smith

22 May 08 13:14

Dr Nowlan makes a very important point. This issue is the subtext to at least some of the debate around record access, sharing and consent. Whilst the lack of agreement that 'running Mrs Smith' is different to 'running the organisation' remains, (and that the former is the most important), then it will be a struggle to deliver integrated care records.

Universal Agreement (er...1 exception)

22 May 08 17:22

I think, there is now a common understanding that there is a discrepancy between running an organisation efficiently and running a patient pathway efficiently. In fact I have seen numerous examples where the former has had a negative impact on the latter - particularly in the 'efficient' discharge of patients into unsuitable support environments.

Actually, many of the orgianisation focussed products are really very good indeed - as good as you will find anywhere - GP products especially, but also some PAS, pathology and acute departmental systems.

It is the tragedy of CFH that they have completely misunderstood the place of these products and how critical they are to the running of an organisation, and thought they could be chopped and changed at will.

So what started out as a good idea, and lets give credit it WAS the vision of NPfIT to improve the efficiency of "running Mrs Smith", turned into the shambles it is today. Becasue you can't "run Mrs Smith" unless you can first run an effective service.

Lets hope that when someone finally bites the bullet performs the radical surgery that CFH needs, there are enough clinicians of foresight and sense to see that that vision is still worth pursuing

Dr Nowlan we're behind you

Departments, records - and information needed...

maryhawking@tigers.demon.co.uk

22 May 08 21:10

Many departments - especially haematology and rehabilitation - cannot function without their detailed records, and as a GP I have discovered over the years that a lot of hospital departments keep private records - sometimes refusing to share any information with the main record. I have often had letters from hospital out-patients along the lines of "records were not available, so I have given the patient a further appointment in 6 months" - which is bad for the patient, frustrating for me, and expensive for my PBC budget! If you look at the absolute minimum information needed, it consists of referral letter, what was done last time and developments since. As all letters these days are generated on word processors, and hospital EPRs - let alone SSEPRs - are not imminent, why not have a trust-wide correspondence file for each patient? It might even have the side-effect of improving the quality of discharges and letters..

It is the Patient that matters...

23 May 08 12:48

The critical flaw in Mary's proposal .... how would BT, Fujitsu and CSC make money out of it ??

From the point of view of the NHS Project Staff I have worked with and met around the country it is the patient and the clinicians that matter.... all the data for Management should be co-incidental to making sure that the clinician giving care has the information they need (and all the information there is) available at the point of care everytime. Yes many of the LSP offerings are only just fit for purpose (legal advice) we can work with them to get some benefits and minimise the problems if we had a little more clinical dialogue at a local level.