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Hospital Healthcare Europe

NHS patients seen without their notes


22 May, 2008  

Data volunteered by hospital trusts has suggested that over a million NHS patients are being seen every year without doctors having access to their full medical records.

A study by the Health Service Journal (HSJ) said there was no standardised way of measuring how many patient records are missing across NHS hospitals each year.

A total of 49 trusts responded to the HSJ’s request for details under the Freedom of Information Act. Some gave a full account of their last audit while others gave details of the percentage of patients seen without their full records.

The analysis, which involved a total of two million outpatient appointments between 2006 and 2008, revealed that around 54,000 appointments took place without the patients’ full records.

If that rate was replicated across the NHS, around 1.2 million outpatients in England are being seen without their notes every year.

The HSJ said that if that rate was replicated across the NHS, some 1.2 million outpatients in England are being seen without their notes every year.

In 1999, the Audit Commission published an update to an earlier report saying that hospitals should aim to have 100% of patient notes available for outpatient appointments.

It found that almost half of trusts had 99% of notes available but said some trusts were still performing below the benchmark of 95% availability of casenotes at clinics.

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