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The importance of Good Record Keeping

A person's medical records are amongst the most sensitive of personal records and great care should be taken to ensure the safe holding of such records. Apart from their sensitive nature, there is also the very practical consideration that they can be of considerable clinical value in relation to the ongoing care of a patient. Their primary purpose is to document the assessments underlying the progress of the patient's care and so contribute to the quality of that care. As months or years may elapse between treatments or illnesses, and staff may have moved on, the records should serve to reconstruct events at a later date without recourse to memory. Poor record keeping can lead a patient's care being adversely affected through;

an increased risk of medication or other treatment being duplicated or omitted, communication problems between staff, both nursing and medical, a failure to focus attention on early signs of change in a patient's condition, and a failure to place on record significant observations and conclusions.

They can also be of great importance in cases alleging medical negligence, or other such litigation, and they may be of value to the family of a patient after he or she has died, provided, of course, that their release is justified in any particular case.

It is the experience of this Office, however, that when we have had occasion to examine patient files we have often found them to be unsatisfactory as a record of the various elements of a period of hospitalisation. International research shows that Ireland is not unique in this situation. Reports in the UK reveal a lack of structure, disorganisation, illegibility, absences of problems or diagnoses. Similar problems were revealed in Australia. In Spain 15% of records reviewed were so illegible as to be rendered meaningless. It is beyond comprehension that caring professions can be so lax in this regard. Such practice could only be described as being akin to a ( no doubt unintentional ) level of disrespect and disregard for the patient.

The retention and efficient management of patients' records should be a key responsibility. In this context the Ombudsman would expect that such records would be legible, intelligible, complete, specific, contemporaneous, signed and dated. Abbreviations should be universally understandable and not open to misinterpretation. They should be written with care (a slip of the pen can easily change the meaning of an abbreviation); that makes life easier for all hospital personnel using the records, for the hospital administration in dealing with any complaint and, ultimately, for the Ombudsman if she has reason to include such records in the examination of a complaint. In addition certain abbreviations are unacceptable (e.g. coded expressions of exasperation, invective or sarcasm).

Deficiencies in Medical Records

Deficiencies in those standards were given concrete reality in a particular case dealt with by the Ombudsman, in which the care and treatment afforded to a patient in the days prior to his unexpected death were under consideration. In that investigation the Ombudsman found a paucity of records covering critical treatment junctures, a stark failure to meet the standards of medical record keeping expected of medical staff following their contact with the patient and an absence of relevant entries on the nursing notes during a period of significant nursing intervention. The paucity of the records made it difficult to establish precisely what happened during the period in question. The absence of medical note entries following examinations raised the question as to how any doctor, who was subsequently called to examine the patient, could quickly apprise himself or herself of the patient's condition, in particular where a previous, but unrecorded, medical examination was significant in terms of diagnosis or treatment. The Ombudsman recommended that the hospital review its procedures to ensure (i) that entries on the nursing records created by nursing staff accurately reflect the contacts made with medical staff for the purposes of patient review and the reason that the contact was made; (ii) that all significant observations on a patient's condition that are made to members of the medical team by the nursing staff are recorded on the nursing notes. Furthermore, the Ombudsman recommended that the responsible health board take action to ensure that all the hospitals under its control meet the standards outlined in the recommendation. The Board accepted these recommendations in full by way of : 

(i) The development of a programme of nurse education relating to best practice in the maintenance of nursing notes, followed by a chart review and audit of nursing documentation to determine the effect of the programme, and generally to monitor documentation.

(ii) The development of a new module in the induction programme for non consultant (Junior) doctors, concentrating on best practice for medical notes.

 

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Annual Report 2013

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