Record Keeping: Setting the record straight
We hosted a webinar that focused on improving record keeping in the NHS.
In 2015-16, there were 3 million outpatient attendances, approximately 500,000 admissions to hospital beds, 120,000 people having diagnostic tests and over 800,000 visits to Accident and Emergency across Wales.
Each of these interactions with the NHS, along with many other interactions with community and primary care services, require a record to be maintained which sets out clearly what happened to the patient. While some of the administrative aspects of these interactions are stored on electronic systems, different clinical professionals will regularly complete separate paper records for the same interaction or episode of care which results in records being fragmented.
In 2001, the National Audit Office found that poor record keeping by NHS bodies had been a contributory factor in over 40% of medical negligence claims. The findings of the Wales Audit Office review of clinical coding in 2014 are consistent with those found by the Audit Commission in 1999, suggesting that not much has changed and that the risk to medical negligence remains the same.
Patients have a justifiable expectation that their records will be freely available to all those who need access to them, and that they will be an accurate and complete record of their care.
The aim of this webinar was to share the approaches, experiences and learning from organisations that have:-
- Taken steps to address the challenges of poor record keeping;
- Made progress with effective sharing of records between primary, secondary and community services; and
- developed innovative approaches to record keeping through the use of smart technology.
Who the webinar was aimed at
This webinar was aimed at staff working in the following areas:
- Medical, nursing and allied health professions
- Quality and safety, including clinical governance and clinical audit
- Risk management
- Medico legal
- Medical records and information