Doctors’ illegible handwriting in medical records could put patients at risk, the Care Quality Commission has said.
During an inspection at Manchester Royal Infirmary, part of Central Manchester University Hospitals NHS Foundation Trust, the CQC found that staff struggled to read the doctors’ paper notes.
A report on the visit, says that this meant there was a risk to patients as they could end up receiving the wrong treatment, and “the record did not provide clear and unequivocal evidence of a patient’s treatment pathway.”
Another problem was that the hospital had no standard way of indexing files, meaning it could be difficult to find the right information at the right time.
One nurse told the CQC that it can be “a nightmare” to decipher doctors’ notes, and another one said: "(We) need to improve records for day case/medical investigations as it can be confusing with so many pieces of different paperwork."
In response to Robert Francis QC’s second report on Mid Staffordshire NHS Foundation Trust, the government announced an overhaul in the way the CQC spots problems, inspects healthcare organisations, and issues information.
It has been setting up a new inspection regime, overseen by new chief inspectors of hospitals, adult social care, and general practice. Part of the new regime, is seemingly a larger focus on record keeping in trusts and the way information is recorded.
Professor Robert Pearson, medical director at Central Manchester said that the concerns raised by the inspectors are known to the trust and it is working to solve them.
“We have invested a huge amount in the management of risks associated with the fact that the records are still, largely, paper based,” he said.
The trust is developing its own electronic patient record system, called Chameleon, which is being trialled in the trust’s eye hospital, before further roll out.
Prof Pearson said he believes the new system will solve many of the issues around record keeping.
“We are working hard to develop a bespoke electronic record which will meet the needs of patient care delivery for all specialties,” he said.
In a visit to Barnet and Enfield and Haringey Mental Health NHS Trust last year, the CQC found that staff had difficulties with the trust’s IT system, and examples of “inadequate record keeping”. However, in a more recent visit, the CQC reported that these issues had now been solved.