Information about the clinical care of hospital patients is recorded in their health records or casenotes. Accurate and comprehensive recording of information and accessibility to this information are essential for effective patient care and continuity of care between different health professionals. Casenotes are also important for teaching, research and clinical audit, as well as being a source of managerial, financial and statistical data for the NHS. It is expected that they will play a key part in demonstrating clinical governance.
In 1995, the Audit Commission's report, Setting the Records Straight, examined a wide range of issues relating to the management of health records services and to the contents of casenote folders. This update reports the results of a follow-up survey of trusts (225 respondents), which was carried out by the Audit Commission early in 1999. It examines the changes that have taken place in the organisation and effectiveness of health records services, the storage of records and their structure and content. Variations in performance in all these areas were similar in both English and Welsh trusts, so results are presented for all trusts together throughout this update.
Included in this report:
- retrieving records for consultations
- storage of records
- structure and contents of casenotes
- organisation and management of health records services
- next steps