Quality of medical record keeping: significance difference between types of admissions

Aims: Although good record keeping is important for continuity of care, little is known about the quality of record keeping. We aimed to assess the quality of medical record keeping amongst gastroenterologists and surgeons in a private hospital.

Methods: 12% of all admissions between January 2003 and June 2004 were randomly selected by computer. Records were scored as – date[1], time[1], page number[1], patient's name[1], hospital number[1] and signature[1] (maximum 7). Legibility was scored as –3[no illegible word], 2[illegible word(s) but reads well], 1[illegible word(s) and does not read well].

Results: 731 notes were studied. Records were absent more in day patients (n=318;84.8% of 375) than inpatients (n=99;27.8% of 356) [p<0.001]. The mean score of record was 1.55±1SE0.07 [maximum 4.4±0.16 (neurosurgeons), minimum 0.13±0.09 (plastic surgeons), 0.20±0.14 (gastroenterologists)]. The score varied significantly (p<0.001) amongst most of the specialities (n=12). The mean score of legibility was 0.79±1SE0.04 [maximum 1.96±0.14 (neurosurgeons), minimum 0.07±0.05 (plastic surgeons), 0.11±0.8 (gastroenterologists)]. The legibility score, however, did not vary (p<0.0001) significantly amongst most of the specialities.

Conclusions: There was a significant association between quality of record keeping and type of admission, and the scores of record keeping and legibility were low. These have medicolegal and clinical governance implications.