Over a million patients seen without records

A poll of NHS acute trusts indicates over 1.2m outpatients in England are seen each year without the clinician having access to a patient’s records.

Health Service Journal magazine surveyed 49 NHS trusts and found that in the last year, around 54,000 outpatient appointments took place without the use of medical records.

Of the 49 trusts, 5% admitted having notes missing, and in total, an average 2.6% of outpatient records were missing.

The magazine says that if the figures were projected nationally, approximately 1.2m outpatients in England would be seen without their notes every year.

A Patients Association spokesperson told E-Health Insider: “This investigation reveals that patient safety is at risk. The solution is 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.”

City Hospitals Sunderland NHS Foundation Trust had the highest rate of notes unavailable, with 19% of outpatient appointments conducted without records.

A spokesman for the trust said the situation was improving and they were recruiting a records manager to address the issue.

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.”

A DH spokesperson told EHI: “The NHS seeks to ensure that everyone has the best level of care possible. The NHS Care Records Service is already helping NHS staff to deliver better, safer, care and we know that part of this is ensuring patient records are kept private, secure and confidential.

“There may of course be some perfectly legitimate reasons that records are not present, as a result of a considered clinical judgement where a patient is well known to the doctor, and where their condition not complex, and stable.”