How Adequate are Hospital Records? - The First Report of the North West Spina Bifida Registry

Abstract

The United Kingdom North West Regional Registry of patients with Neural Tube Defects was established in June 1996. The aims of the registry are to keep a record of all patients in a defined geographical location with neural tube defects and to ensure appropriate facilities and follow-up are available. During the first year of the registry 217 patients have been identified and the hospital records of 163 of these reviewed. This report deals with the shortcomings of hospital records identified during this exercise. We identified many inaccuracies and omissions when reviewing case notes. 3 % of patients had unclear records as to the presence/ absence of shunts. Bladder management was unclear in 17% of patients and bowel management in 26% of cases. There was no record as to the presence/absence of hydronephrosis or renal scarring in 24% and 34% of patients respectively, no blood pressure measurement in 50 % of patients and no record of a serum creatinine in 56%. Mobility was not recorded in over 30% of patients. Developmental achievement and school placement were rarely if ever recorded.

These results demonstrate the problems with the current medical record system. The potential consequences of this are discussed and means of improving record systems suggested.

Key words

Neural tube defects - Registry - Medical records - Medical coding - Information