Inadequacies of hospital medical records

Abstract

We have assessed the extent to which hospital records follow the Guidelines for Medical Records and Notes published by the Royal College of Surgeons of England. Notes of 100 consecutive discharges were reviewed from two surgical units, one at a District General Hospital (DGH) and the other at a London Teaching Hospital (TH). Overall, only 65 per cent (DGH) and 67 per cent (TH) of the entries specified by College guidelines were both present and correct. Substandard categories included the regular update of notes, post-operative instructions, comments about post-operative recovery, the record of advice given to relatives and incorrect consent. The guidelines produced by the Royal College of Surgeons are being applied, but there is room for considerable improvement. Inadequate medical records limit audit and may have medico-legal consequences. We recommend regular assessment of the standard of note keeping.