Setting the records straight - a prospective audit of the quality of case notes in a surgical department

Abstract

Background. A high standard of medical record keeping is important for safe patient care and provides information for research, audit and medicolegal purposes. Standards exist on what entries should contain, but as far as we are aware these standards are not regularly used in South Africa. We compared surgical case notes at Prince Mishyeni Hospital with guidelines from the Royal College of Surgeons of England. Patients and methods: A prospective series of 204 case notes was randomly selected and reviewed.
Results. There was an 80% compliance rate for 16/35 standards, and 100% was achieved for 8 operation sheet standards. The following fell short of 80% compliance: patient\'s
name on every page (71%), hospital number on every page (50%), every entry timed (16%), clinician\'s name printed on every note (8%), clinician\'s designation on every entry
(2%), an entry each weekday (77%), type of admission (9%), presenting complaint (61%), history of presenting complaint (65%), previous medical history (76%), drug history (47%),
allergies (59%), social history (34%), family history (11%), each entry legible (65%), and anaesthetist\'s name (69%). Test results were signed and radiograph test results initialled
in 25% and 17% of cases respectively. Conclusion. Legal requirements, good practice, research and teaching all demand notes that are detailed and of high quality. This study shows that medical records are grossly inadequate in many respects. Better education of junior staff and regular auditing of medical records could improve this.

South African Journal of Surgery Vol. 45 (3) 2007: pp. 92-94