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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 study presented here examines the reporting of patient‐to‐patient bullying in a high secure psychiatric hospital housing adult men. It examines official records of bullying recorded on Suspected Bullying Report forms (SBRs), noting motivations for bullying and exploring how information was recorded. Its subsidiary aim was to explore the value of official records, presenting comparison data from three patient bullying surveys completed at the same hospital. All suspected reports of bullying in the hospital documented for a two‐year period were collected. The patient surveys included data from three data‐sets collected at the same hospital over a five‐year period. The prediction that the patient surveys would suggest a higher level of bullying behaviours than official records was confirmed. Results for official records also demonstrated that motivation for bullying was either not recorded or was reported as a typology, bullying was not likely to be recorded as hospital incidents, and perpetrators were unlikely to be offered supportive intervention. The results are discussed with regard to the value of official records as a reporting mechanism.

This chapter proposes an optimized innovative information technology as a means for achieving operational functionalities of real-time portable electronic health records, system interoperability, longitudinal health-risks research cohort and surveillance of adverse events infrastructure, and clinical, genome regions – disease and interventional prevention infrastructure. In application to the Dod-VA (Department of Defense and Veteran's Administration) health information systems, the proposed modernization can be carried out as an “add-on” expansion (estimated at $288 million in constant dollars) or as a “stand-alone” innovative information technology system (estimated at $489.7 million), and either solution will prototype an infrastructure for nation-wide health information systems interoperability, portable real-time electronic health records (EHRs), adverse events surveillance, and interventional prevention based on targeted single nucleotide polymorphisms (SNPs) discovery.

This paper examines existing research on the topic of personal health records (PHRs). Areas covered include PHR/patient portal, recordkeeping, preservation planning, access and provider needs for future reuse of health information. Patient and physician PHR use and functionality, as well as adoption facilitators and barriers, are also reviewed.

The paper engages in a review of relevant literature from a variety of subject domains, including personal information management, medical informatics, medical literature and archives and records management literature.

The review finds that PHRs are extensions of electronic records. In addition, it finds a lack of literature within archives and records management that may lead to a less preservation-centric examination of the new PHR technologies that are desirable for controlling the lifecycle of these important new records-type.

Although the issues presented by PHRs are issues that can best be solved with the use of techniques from records management, there is no current literature related to PHRs in the records management literature, and that offered in the medical informatics literature treats the stewardship aspects of PHRs as insurmountable. This paper offers an introduction to the aspects of PHRs that could fruitfully be examined in archives and records management.

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.

The paper seeks to examine how an online maternity record involving pregnant women worked as a means to create shared maternity care.

Ethnographic techniques have been used. The paper adopts a theoretical/methodological framework based on science and technology studies.

The paper shows how a version of “the responsible patient” emerges from the project which is different from the version envisioned by the project organisation. The emerging one is concerned with the boundary between primary and secondary sector care, and not with the boundary between home and clinic, which the project identifies as problematic and seeks to transgress.

The pilot project, which is used as a case, is terminated prematurely. However, this does not affect the fact that more attention should be paid to the specific redistribution of responsibilities entailed in shared care projects. Rather than seeking to connect all actors in an unbounded space, shared care might instead suggest a space for patients and professionals to experiment with new roles and responsibilities.

When designing coordination tools for health care, IT designers and project managers should attend to the specific ways in which boundaries are inevitably enacted and to the ways in which care is already shared. This will provide them with opportunities to use the potentials of new identities and concerns that emerge from changing the organisation of healthcare in relation to IT design.

The paper shows that “unshared” care does not exist; care is always shared among human and nonhuman actors. It also points to the value of studying how boundaries are enacted in projects that seek to create continuity across boundaries.

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 pre‐operative anaesthetic records of 195 patients were analysed for the presence of 12 agreed core items of pre‐operative assessment. This study showed that anaesthetists recorded 26.8 per cent of this information. In up to one‐third of patients the following were recorded: smoking history, family history, gastro‐oesophageal reflux, airway assessment, dental assessment, chest examination, heart‐sounds and blood pressure. Previous anaesthesia, drug history and allergies were recorded in one to two‐thirds of patients. Past medical history was recorded in over two‐thirds of patients. With a view to improving the level of record‐keeping, a formatted, pre‐printed pre‐operative assessment record was introduced into practice and two months later the audit was repeated. A small but non‐significant improvement in record keeping was observed. An argument is made for the introduction of an interdisciplinary, unified anaesthetic pre‐operative record.

This paper aims to investigate the perception of Egyptian patients about the use of personal health records (PHRs).

A quantitative research methodology was adopted in the form of a survey.

Over one-third of the selected sample was found to use PHRs. The study found that the use of PHRs by Egyptian patients was moderate. All PHRs users confirmed that they were very interested in the doctors’ notes and the laboratory reports recorded in their records. A very large number of PHR users confirmed that their use of these records was at least fairly easy for them and all of them confirmed that the use of these records was at least fairly useful. Above two-third of PHR users answered at least “somewhat yes” that their PHRs were accurate and over half of them answered at least “somewhat yes” that their PHRs were complete. The highest percentage of PHR users agreed that the use of PHRs would enhance their trust in their doctors and nurses. Close to half of PHR users expressed some concern about sharing their records. Violation of privacy in the use of these medical records, followed by the complexity of using them, as well as lack of awareness about them, was also significant to PHR users.

Understanding Egyptian patients perceptions of using PHRs may significantly aid in eliminating barriers and accelerating the adoption and use of these records to improve patient care.