Page last updated at 23:00 GMT, Wednesday, 21 May 2008 00:00 UK

Patient safety worry over records

medical records
Thousands of patients were seen by doctors without their medical records

Concerns have been raised over patient safety, after a poll revealed thousands of appointments are taking place without the patient's records.

Around 54,000 outpatient appointments took place with no records across the 49 hospital trusts who responded.

The investigation, by the Health Service Journal (HSJ) said there was no standardised way of measuring how many patient records are missing each year.

A medical expert said it was dangerous not to have patient records available.

If you haven't got the records you haven't got a true history of the patient sitting in front of you. You don't know who you are treating or what is wrong with them
Vanessa Bourne, Patients Association

The HSJ found six out of the 49 trusts had 5% or more notes missing. On average 2.6% of outpatient records were missing.

City Hospitals Sunderland NHS Foundation Trust reported the highest rate, with 19% of outpatient records unavailable at the start of clinic.

A spokesman for the trust told the HSJ the situation was improving and a new position had been created to address the issue.

The analysis of over two million outpatient appointments at 49 hospitals was of the period between 2006 and 2008.

Richard Vize, editor of the Health Service Journal said if that rate is replicated across the NHS approximately 1.2 million outpatients in England will be seen without their notes every year.

The HSJ said trusts may downplay the extent of the missing records, for example by cancelling appointments where full details are not available or by creating temporary records.

Dangerous

Professor John Williams, from the Royal College of Physicians said not having the full patient record at the time of the appointment was dangerous.

"There may be issues about the patient you are not aware of.

"It becomes a self perpetuating and escalating problem because once the notes go missing you end up creating multiple duplicate records."

Vanessa Bourne from the Patients Association said the investigation reveals that patient safety is at risk.

She said the solution was for patients to keep their own records.

"There has always been a cavalier attitude to records. Other businesses would not get away with this.

"If you haven't got the records you haven't got a true history of the patient sitting in front of you. You don't know who you are treating or what is wrong with them."


SEE ALSO
Hospital to 'tag' patient records
11 May 08 |  West Midlands
Patient veto for e-care records
18 Dec 06 |  Health

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