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Ireland’s physicians have a legal and an ethical duty to protect confidential patient information. Most healthcare records in Ireland remain paper based, so the purpose of this paper is to: assess the protection afforded to paper records; log highest risk records; note the variations that occurred during the working week; and observe the varying protection that occurred when staff, students and public members were present.

A customised audit tool was created using Sphinx software. Data were collected for three months. All wards included in the study were visited once during four discrete time periods across the working week. The medical records trolley’s location was noted and total unattended medical records, total unattended nursing records, total unattended patient lists and when nursing personnel, medical students, public and a ward secretary were visibly present were recorded.

During 84 occasions when the authors visited wards, unattended medical records were identified on 33 per cent of occasions, 49 per cent were found during weekend visiting hours and just 4 per cent were found during morning rounds. The unattended medical records belonged to patients admitted to a medical specialty in 73 per cent of cases and a surgical specialty in 27 per cent. Medical records were found unattended in the nurses’ station with much greater frequency when the ward secretary was off duty. Unattended nursing records were identified on 67 per cent of occasions the authors visited the ward and were most commonly found unattended in groups of six or more.

This study is a timely reminder that confidential patient information is at risk from inappropriate disclosure in the hospital. There are few context-specific standards for data protection to guide healthcare professionals, particularly paper records. Nursing records are left unattended with twice the frequency of medical records and are found unattended in greater numbers than medical records. Protection is strongest when ward secretaries are on duty. Over-reliance on vigilant ward secretaries could represent a threat to confidential patient information.

While other studies identified data protection as an issue, this study assesses how data security varies inside and outside conventional working hours. It provides a rationale and an impetus for specific changes across the whole working week. By identifying the on-duty ward secretary’s favourable effect on medical record security, it highlights the need for alternative arrangements when the ward secretary is off duty. Data were collected prospectively in real time, giving a more accurate healthcare record security snapshot in each data collection point.

The focus of this paper is on the mediating role of medical records in patient care. Their informative, communicative and constitutive facets are analysed on the basis of a case study in an African University teaching hospital.

A practice-oriented approach and the concept of boundary objects were adopted to examine medical records as information artefacts. Data from nonparticipant observations and interviews with physicians were triangulated in a qualitative analysis.

Three distinctive practices for information sharing – absorbing by reading, augmenting by documenting and recounting by presenting – were identified as central to the mediating role of medical records in the care of patients. Additionally, three information-sharing functions outside the immediate care of patients were identified: facilitating interactions, controlling hegemonic order and supporting learning. The records were both a useful information resource and a blueprint for sustaining shared practices over time. The medical records appeared as an essential part of patient care and amendments to them resulted in changes in several other work practices.

The analysis contributes to research on documents as enacting and sustaining work practices in a workplace.

Medical record represents the main information support used by healthcare providers. The purpose of this paper is to examine whether patient perception of hospital care quality related to compliance with medical-record keeping.

The authors merged the original data collected as part of a nationwide audit of medical records with overall and subscale perception scores (range 0-100, with higher scores denoting better rating) computed for 191 respondents to a cross-sectional survey of patients discharged from a university hospital.

The median overall patient perception score was 77 (25th-75th percentiles, 68-87) and differed according to the presence of discharge summary completed within eight days of discharge (81 v. 75, p=0.03 after adjusting for baseline patient and hospital stay characteristics). No independent associations were found between patient perception scores and the documentation of pain assessment and nutritional disorder screening. Yet, medical record-keeping quality was independently associated with higher patient perception scores for the nurses’ interpersonal and technical skills component.

First, this was a single-center study conducted in a large full-teaching hospital and the findings may not apply to other facilities. Second, the analysis might be underpowered to detect small but clinically significant differences in patient perception scores according to compliance with recording standards. Third, the authors could not investigate whether electronic medical record contributed to better compliance with recording standards and eventually higher patient perception scores.

Because of the potential consequences of poor recording for patient safety, further efforts are warranted to improve the accuracy and completeness of documentation in medical records.

A modest relationship exists between the quality of medical-record keeping and patient perception of hospital care.

The purpose of this article is to assess the reliability of an in‐depth analysis on causation, preventability, and disability by two separate review teams on five selected adverse events in acute hospitals: pressure ulcer, postoperative pulmonary embolism or deep vein thrombosis, postoperative sepsis, ventilator‐associated pneumonia and postoperative wound infection.

The analysis uses a retrospective medical record review of 1,515 patient records by two independent teams in eight acute Belgian hospitals for the year 2005. The Mann‐Whitney U‐test is used to identify significant differences between the two review teams regarding occurrence of adverse events as well as regarding the degree of causation, preventability, and disability of found adverse events.

Team 1 stated a high probability for health care management causation in 95.5 per cent of adverse events in contrast to 38.9 per cent by Team 2. Likewise, high preventability was considered in 83.1 per cent of cases by Team 1 versus 51.7 per cent by Team 2. Significant differences in degree of disability between the two teams were also found for pressure ulcers, postoperative pulmonary embolism or deep vein thrombosis and postoperative wound infection, but not for postoperative sepsis and ventilator‐associated pneumonia.

New insight on the degree of and reasons for the huge differences in adverse event evaluation is provided.

This study aims to develop a framework for the management of medical records in support of health-care service delivery in the hospitals in the Limpopo province of South Africa.

The study was predominantly quantitative and has used the questionnaires, system analysis, document analysis and observation to collect data in 40 hospitals of Limpopo province. The sample of 49 per cent (306) records management officials were drawn out of 622 (100 per cent) total population. The response rate was 71 per cent (217) out of the entire sample.

The study discovered that a framework for management of medical records in the public hospitals is not in place because of several reasons and further demonstrates that public health-care institutions need an integrative framework for the proper management of medical records of all forms and in all media.

The study develops and suggests a framework to embed medical records management into the health-care service delivery workflow for effective records management and ease of access. It is hoped that such a framework will help hospitals in South Africa and elsewhere to improve their medical records management to support health-care service provision.

The Audit Commission is the statutory body which oversees the external audit of local authorities and agencies within the National Health Service in England and Wales. As part of its function the Commission reviews the economy, efficiency and effectiveness of services provided by these bodies by undertaking studies and audits of selected topics each year. The study of medical records was one of these.

The purpose of the paper is to determine the instance of errors made in physician dictation of medical records.

Purposive sampling method was employed to select medical transcriptionists (MTs) as “experts” to identify the frequency and types of medical errors in dictation files. Seventy-nine MTs examined 2,391 dictation files during one standard work day, and used a common template to record errors.

The results demonstrated that on the average, on the order of 315,000 errors in one million dictations were surfaced. This shows that medical errors occur in dictation, and quality assurance measures are needed in dealing with those errors.

There was no potential for inter-coder reliability and confirming the error codes assigned by individual MTs. This study only examined the presence of errors in the dictation-transcription model. Finally, the project was done with the cooperation of MTSOs and transcription industry organizations.

Anecdotal evidence points to the belief that records created directly by physicians alone will have fewer errors and thus be more accurate. This research demonstrates this is not necessarily the case when it comes to physician dictation. As a result, the place of quality assurance in the medical record production workflow needs to be carefully considered before implementing a “once-and-done” (i.e. physician-based) model of record creation.

No other research has been published on the presence of errors or classification of errors in physician dictation. The paper questions the assumption that direct physician creation of medical records in the absence of secondary QA processes will result in higher quality documentation and fewer medical errors.

Despite the presence of electronic medical records systems, traditional paper-based methods are often used in many countries to document data and eliminate medical record deficiencies. These methods waste patient and hospital resources. The purpose of this study is to evaluate the traditional deficiency management system and determine the requirements of an electronic deficiency management system in settings that currently use paper records alongside electronic hospital information systems.

This mixed-method study was performed in three phases. First, the traditional process of medical records deficiency management was qualitatively evaluated. Second, the accuracy of identifying deficiencies by the traditional and redesigned checklists was compared. Third, the requirements for an electronic deficiency management system were discussed in focus group sessions.

Problems in the traditional system include inadequate guidelines, incomplete procedures for evaluating sheets and subsequent delays in activities. Problems also included the omission of some vital data elements and a lack of feedback about the documentation deficiencies of each documenter. There was a significant difference between the mean number of deficiencies identified by traditional and redesigned checklists (p < 0.0001). The authors proposed an electronic deficiency management system based on redesigned checklists with improved functionalities such as discriminating deficiencies based on the documenter’s role, providing systematic feedback and generating automatic reports.

Previous studies only examined the positive effect of audit and feedback methods to enhance the documentation of data elements in electronic and paper medical records. The authors propose an electronic deficiency management system for medical records to solve those problems. Health-care policymakers, hospital managers and health information systems developers can use the proposed system to manage deficiencies and improve medical records documentation.

The purpose of this study is to determine the extent to which total quality management (TQM) initiatives can improve the quality of services delivery at the medical records unit of the Korle-Bu Teaching Hospital (KBTH) to help meet the expectations and aspirations of patients and customers of the hospital.

This research adopted the survey strategy as its research design. The total study population consisted of 114 medical records staff of the KBTH. Questionnaires and personal observations were employed as the data collection instruments. The study recorded a response rate of 98 per cent. Data gathered from respondents were analysed in qualitative terms.

The overall finding of this study was that, although the medical records department of the KBTH had a fair degree of understanding on the benefits of TQM to records management service delivery, the exiting values for TQM did not meet the framework of good TQM practice, principles and standards.

Even though the subjects for the study were from the biggest hospital in Ghana, the findings of this study may not be generalised to the whole country.

The study has demonstrated the need for the medical records department of the KBTH to have and develop good TQM standards to improve the quality of services to patients and varied customers of the hospital.

The literature reviewed indicated that this study is a maiden attempt to examine how TQM initiatives including sensitivity, customer satisfaction, commitment of top management, team work, effective leadership and participatory management, people development and effective and open communication can improve the quality of medical records service delivery at the KBTH in Ghana.

Evaluates care plans documented in two different ways, using controlled and randomised studies of consecutive acutely admitted medical patients. Within 24 hours after admission, a care plan was made for the hospital stay, specifying active problems, a plan of action and a time‐schedule. In study 1, patients had care plans written directly into their medical records during the intervention period, while the normal admittance procedure was followed in the control period. In study 2, all patients had a care plan made on a planning form and in the medical record. Patients were randomised either to have the form stay in the medical record or to have it removed. Study 1 results showed that care plans were associated with earlier recognition of patients’ active problems, whereas the tendency to initiate solutions to active problems earlier was insignificant. Length of stay (LOS) and risk of readmission remained unchanged. In study 2, planning forms were associated with a 1.5‐day lower LOS and higher accuracy of planned LOS. Risk of readmission and accomplishment of plans of action were unaltered.