Patient records: jokes about doctors’ bad handwriting are no longer funny
The Audit Commission has found that 8 per cent of the bills sent by trusts to commissioners last year were for the wrong treatment.
It has raised concerns about the poor state of patient records after its checks found many of them contain unreliable, illegible, or no information.
The importance of getting the bills right cannot be understated. This is about far more than the technicalities of payment by results.
Primary care trusts need accurate information on which to base commissioning decisions; acute trusts must know what work they have carried out in order to improve both efficiency and quality.
And the notion that under choice money follows the patient only holds water if it is possible to check what the patient was treated for in the first place.
The commission warns that some clinical notes are so sloppy they are unsafe to audit at all. If they are unsafe for auditors, they are certainly unsafe for patients.
The importance of keeping accurate records is only going to increase. Last week’s publication of the names of trusts that had sparked mortality rate alerts by the Care Quality Commission, and the imminent completion of the first pilot quality accounts, underline the unassailable march towards more and more data being in the public domain.
If they do not already, all staff - clinical and non-clinical - must be made to understand the importance of keeping accurate records. If they need clearer guidelines or fresh training, managers must make sure they can access it.
If the Conservatives’ plan to give patients access to their own records is realised, it won’t just be the Audit Commission shouting up if the information is not there.
Have your say
You must sign in to make a comment.
Share
Readers' comments (1)
Tim Webb | 1-Sep-2009 12:51 pm
Not wishing to denigrate the problems of the bean counters the real lack of joke is that patients notes are now so thick and full of repetitive junk that they are now useless when it comes to finding vital facts in previous history - sometimes on the current admission - to the detriment of the patient. I have recently gone through a 5cm thick pile of notes with a friend recently - she, quite rightly, was concerned after her mother had, apparently unexpectedly died. After 2 hours working through I was able to discover that death was probably inevitable but also that vital data had been lost when the old notes had been destroyed -presumably there will be a microfiche somewhere but even if there was there is no facility for reading it.
Very few workers on the ward floor have 2 hours to plough through sets of notes in case there is something important somewhere.
This note thickening is recent and driven by fears of legal action - perhaps we should sue the lawyers rather that the hospitals when patients suffer, as for the beans -I am afraid it all seems to be a job creation type of game...
Unsuitable or offensive?