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Article
Publication date: 16 April 2018

Gerard Lambe, Niall Linnane, Ian Callanan and Marcus W. Butler

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…

Abstract

Purpose

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.

Design/methodology/approach

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.

Findings

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.

Practical implications

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.

Originality/value

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.

Details

International Journal of Health Care Quality Assurance, vol. 31 no. 3
Type: Research Article
ISSN: 0952-6862

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Article
Publication date: 6 April 2020

Esther Ebole Isah and Katriina Byström

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…

Abstract

Purpose

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.

Design/methodology/approach

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.

Findings

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.

Originality/value

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

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Article
Publication date: 8 July 2014

Van Mô Dang, Patrice François, Pierre Batailler, Arnaud Seigneurin, Jean-Philippe Vittoz, Elodie Sellier and José Labarère

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…

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3187

Abstract

Purpose

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.

Design/methodology/approach

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.

Findings

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.

Research limitations/implications

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.

Practical implications

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.

Originality/value

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

Details

International Journal of Health Care Quality Assurance, vol. 27 no. 6
Type: Research Article
ISSN: 0952-6862

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Article
Publication date: 28 September 2012

Sandra Verelst, Jessica Jacques, Koen Van den Heede, Pierre Gillet, Philippe Kolh, Arthur Vleugels and Walter Sermeus

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…

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1310

Abstract

Purpose

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.

Design/methodology/approach

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.

Findings

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.

Originality/value

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

Details

International Journal of Health Care Quality Assurance, vol. 25 no. 8
Type: Research Article
ISSN: 0952-6862

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Article
Publication date: 18 May 2018

Ngoako Solomon Marutha and Mpho Ngoepe

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.

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2135

Abstract

Purpose

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.

Design/methodology/approach

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.

Findings

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.

Originality/value

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.

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Article
Publication date: 1 January 1996

LORRAINE NICHOLSON

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…

Abstract

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.

Details

Records Management Journal, vol. 6 no. 1
Type: Research Article
ISSN: 0956-5698

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Article
Publication date: 3 March 2014

Gary C. David, Donald Chand and Balaji Sankaranarayanan

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

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729

Abstract

Purpose

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

Design/methodology/approach

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.

Findings

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.

Research limitations/implications

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.

Practical implications

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.

Originality/value

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.

Details

International Journal of Health Care Quality Assurance, vol. 27 no. 2
Type: Research Article
ISSN: 0952-6862

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Article
Publication date: 18 July 2016

Emmanuel Adjei and Monica Mensah

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

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1605

Abstract

Purpose

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.

Design/methodology/approach

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.

Findings

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.

Research limitations/implications

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.

Practical implications

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.

Originality/value

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.

Details

Records Management Journal, vol. 26 no. 2
Type: Research Article
ISSN: 0956-5698

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Article
Publication date: 1 June 2003

Gustav From, Lone Mark Pedersen, Jette Hansen, Morten Christy, Thomas Gjørup, Niels Thorsgaard, Hans Perrild, Olaf Bonnevie and Anne Frølich

Evaluates care plans documented in two different ways, using controlled and randomised studies of consecutive acutely admitted medical patients. Within 24 hours after…

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2500

Abstract

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.

Details

Clinical Governance: An International Journal, vol. 8 no. 2
Type: Research Article
ISSN: 1477-7274

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Article
Publication date: 9 March 2015

Lorraine Dong

– The purpose of this paper is to present an argument for taking the long view of the retention and preservation of inactive medical records.

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1929

Abstract

Purpose

The purpose of this paper is to present an argument for taking the long view of the retention and preservation of inactive medical records.

Design/methodology/approach

Using the theoretical framework of Actor-Network Theory, the author examines medical records, and especially mental health records, as actants that participate in the classification and treatment of patients, and in the development of psychiatry and mental hospitals as social institutions.

Findings

The varied and profound roles of medical records demonstrate the ability for records to have multiple “lives” that can touch many individuals beyond a single human lifetime.

Practical implications

As the current and future custodians of historical medical record collections, information professionals are in a position to be greater advocates for the increased preservation of and mindful access to these materials.

Social implications

Medical records have potential to be cultural heritage documents, especially for emergent communities.

Originality/value

This paper articulates the ways in which medical records are an embedded part of many societies, and affect the ways in which illness is defined and treated. It thus suggests that while laws regarding the retention and destruction of and access to medical records continue to be deliberated upon around the world, such records can have enduring value as information artifacts.

Details

Journal of Documentation, vol. 71 no. 2
Type: Research Article
ISSN: 0022-0418

Keywords

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