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Inspection report

Date of Inspection: 15 March and 13 April 2011
Date of Publication: 6 June 2011
Inspection Report published 6 June 2011 PDF

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People's personal records, including medical records, should be accurate and kept safe and confidential (outcome 21)

Meeting this standard

We checked that people who use this service

  • Their personal records including medical records are accurate, fit for purpose, held securely and remain confidential.
  • Other records required to be kept to protect their safety and well being are maintained and held securely where required.

How this check was done

Our judgement

Although there is no evidence of inappropriate care and treatment, people who use services cannot be confident their personal records are always completed fully, held securely, and not kept longer than necessary.

User experience

We spoke with two patients who confirmed their notes were available at the time of admission and remained with them as they moved between departments in the hospital. Two people we spoke with in outpatients told us different providers were involved in their care and letters about their consultations were sent to the others so that everyone knew what was happening, and everything worked smoothly. Another patient said there was a clear system that meant staff in different departments were confident they were treating the right person and used his notes to discuss the treatments he had received so far and explain the next stage of the treatment programme.

Other evidence

The hospital manager told us the hospital uses three main computerised record keeping systems to store patient information and activity. Each system is password controlled and access depends on staff grade and role. Systems track a patient’s care pathway, care records as a patient moves between departments, and discharge. The opening page of one electronic system alerts users to patient records that are lost or missing. We saw there were only eight lost or missing records across the two hospital sites on the day we visited. None of them were for patients in the departments we visited, but staff explained the process to trace the missing records.

The information on patients who attend as “day cases” is kept as paper records only. The medical records department generates an “outcome slip” that is attached to the notes and is used to record each stage of the patient’s care during the day. One member of staff in outpatients explained that at the end of each clinic, referral information is posted out by medical secretaries. In the out-patient departments, there is a secure system to ensure records are transferred between medical records and the clinic.

Staff told us a patient’s notes travel with them when they transfer from one ward to another within the hospital. There is a handover of the notes and information about the patient when they arrive on the ward. Staff were aware of the key issues of information management such as only sharing information on a need to know basis and recording only relevant information in a professional way. The hospital has a suitable protocol for the sharing of information with other providers.

There is a central admissions office at the main site (King’s Mill Hospital), available twenty fours hours a day, seven days a week. Records are transported daily between the two hospital sites using the hospital transport system, in order to maintain security.

We looked at a record of the 22 documented incidents relating to patient notes during the year April 2010 to March 2011. These included delays in obtaining healthcare records, failure to note relevant information in patients’ records, and patients incorrectly identified. Actions taken to investigate the incidents and prevent recurrence and were generally clear.

We spoke with different grades of staff about how they make sure accurate personalised records are kept and maintained. They told us staff induction includes records management training and this training is refreshed periodically. Staff check the patient’s identity so as to access the correct records, and patient identity wristbands can be printed on the wards. All types of records are updated as soon as possible and some paper records that are used frequently, such as food and fluid charts, are kept at the patient’s bedside. Other records are kept at the ward desk and staff follow the agreed filing system. Some of the individual paper records in regular use had not been secured within the file but were tucked in the front for ease of access, which increased the risk of them being misplaced.

The records we saw included information to identify the patient, entries were dated and signed and contained information that was relevant to the clinical assessment and treatment. Patient case notes did not always document special social or cultural needs; the care plan provided little space for this type of information and there were no entries in any of the ones we looked at. Care plans did not record how people were involved in decision making, and we found only minimal recording of what information had been given to patients about their care and treatment.

We saw that records not in use or waiting to be collected for archiving or transfer were not always stored in a lockable cabinet, so could have been seen by other patients, visitors or non-clinical staff. We also saw some computer monitors facing out toward public areas, which may compromise confidential information. The local primary care trust