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A random cross-sectional observational study on 100 orthopaedic inpatient case notes in order to evaluate their filing standards

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Abstract:

Properly maintained medical records carry a longlasting medico-legal significance. The Royal College of Surgeons of England recommends that the hospital records must be maintained in a tidy condition and proper maintenance ensured. The King's Fund filing guidance suggests that no papers should be left loose in the notes, and records should be bound and stored properly, so that loss of documents is minimised. We performed a random cross-sectional observational study on 100 case notes of hospital inpatients in an orthopaedic firm in a university teaching hospital of the UK, with regard to their existing filing standards.

We found that the quality of filing standards of case notes is poor. Good filing is important for the longevity of the files. Voluminous loading with unnecessary contents in the file and its pocket leads to premature file fracture and pocket perforation. Better education of the junior and nursing staff and ward clerks, and regular auditing of medical records could improve this.

Keywords: CASE NOTES; FILING STANDARDS; ORTHOPAEDIC FIRM

Document Type: Miscellaneous

Affiliations: 1: Specialist Registrar, Department of Trauma and Orthopaedics, Western Infirmary, Glasgow, UK 2: Consultant, Department of Trauma and Orthopaedics, Southampton General Hospital, Southampton, UK

Publication date: September 1, 2004

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