A major Scottish hospital has been told to immediately improve its electronic patient record, after an inspection found staff were not able to access, and often did not record, patient assessments.

Health Improvement Scotland’s unannounced inspection of care of older people at the Royal Infirmary of Edinburgh, run by NHS Lothian, last year found 13 areas for improvement, including the trust’s EPR.

In a report released this week, inspectors said many staff had difficulty using a new electronic system for risk assessment that the hospital had recently introduced, particularly when it came to accessing previous assessments and results.

“We were told that staff had received training, but ward staff could not always demonstrate how to access patients’ previous assessments or results on the electronic system.”

The inspectors reviewed the hydration and nutrition assessments of 29 patients and found no record of their weight or height in the system. Of the 18 patients that had previously identified as requiring rescreening for malnutrition, it was unclear within the system how many had been reassessed.

No oral health assessments had been completed, some falls were not assessed, and there was difficultly accessing assessments on admission, the inspectors found.

“Due to the electronic health record system in use, we cannot be assured that the care provided was appropriate. For this reason, we are unable to state the numbers of patient assessments correctly completed within the national required timeframes.”

The report said the trust must improve its system to provide accurate and accessible patient record or, if this could not be immediately achieved, put in place an interim alternative.

In a statement, NHS Lothian interim chief officer Jacquie Campbell said the record had improved since the inspection.

“We have made further positive changes to the electronic patient health record system, this includes updates to the system itself making it easier to use, as well further training for all staff.”

The patient frailty team has also expanded and were completing “fuller assessments” on older people on admission to the hospital’s emergency department.

Like nearly all hospitals in Scotland, NHS Lothian uses InterSystem’s TrakCare EPR, and was one of the first in the country to deploy the system in 2006.

Despite the report singling out the hospital's EPR, NHS Lothian said in additional statement that issues raised related to a recently upgraded piece of assessment functionality developed inhouse rather than by Intersystems.

These upgrades included logging some assessments, such as falls and nutrition, electronically, when previously this process had been paper-based.

This story was updated on 17 November, when NHS Lothian provided an additional statement clarifying that issues raised with its EPR related to functionality developed inhouse rather than by Intersystems.