Management of Medical Records at the Surgical Department of a Tertiary Hospital in Blackpool, UK: Results of an Internal Audit

Abstract

Introduction: A medical record a fundamental component of a doctor’s roles and responsibilities in providing objective and evidence-based care to his/her patients. It ensures that everyone treating the patients clearly understands the patient’s needs. According to Good Medical Practice & Good Surgical Practice guidelines, medical records should be taken in real time and should be accurate, legible, comprehensive, honest, non-judgmental and up-to-date. In this study we audited medical records at the surgical department of our hospital in the UK to assess the practice of medical records taking at the hospital. Materials and Methods: This was a follow-up audit to a baseline audit conducted in April 2021.  This study was conducted from 24th January 2022 to 30th January 2022 at the surgical admission unit of Blackpool Victoria Teaching Hospital. A total of 47 sets of records corresponding to 47 emergency surgical take patients were selected and assessed in details against pre-determined assessment criteria. Data was analyzed in Microsoft excel software and summarized inform of count and percentages and presented in bar graphs. Results: A total of 47 sets of records were assessed for completeness based on the selected parameters. Overall, there was improvement in recording patient ID, recording of reviewing physician’s name, recording of examination findings, recording of patient management plan, and recording of final National early warning score (NEWS). Recording of reviewer name, date, and patient management plan had more than 80% improvement, while the rest were averagely recorded, ranging from 40 to 60%. Conclusion: The result indicated that documentation in the surgical unit was still inadequate as only three parameters; reviewer name, date and plan were being well recorded. However, there is still a lot of room for improvement and discussions are underway to implement the electronic medical records system.