AN AUDIT ON THE COMPLETENESS OF THE PATIENT RECORDS: MAY RETROSPECTIVE STUDIES BE DONE?

Abstract

The completeness of patients' records in a department of general surgery of a tertiary referral hospital was evaluated to understand whether the retrospective studies could be performed without any data loss. Retrospective studies raise questions for further research and the quality of the patient records determines the success of the study. This study was conducted on hospital records of 200patients who were treated between January 1st, 1992 and May 31S|, 1992 at the Hacettepe University School of Medicine Department of General Surgery. The first patient file was selected randomly between the first five files. The consequent fifth files were included in the study. In case of missing files, the consequent fifth file was noted. Present and past medical history, family history, physical examination, laboratory results, operative records, pre- and postoperative progress records, discharge summary and follow-up records were evaluated. Laboratory results that were not required in treatment of the patients were not included in the evaluation process. Eighty two percent (n: 164) of present medical history and 93% (n: 186) of physical examination records were found to be complete. Of the laboratory results; 98% (n:192) of complete blood count, 96%(nil96) of serological studies and 67.5% (nil35) of ECG were recorded. Operative notes in 79.5%(n:159), postoperative progress notes in 50.5% (n:101), discharge summaries in 64.5% (n:129) and follow-up records in 18% (n:36) of the patients' files were written in a standard format. Patients' records must be written carefully by the residents. Junior residents should take place in clinical studies so that they should understand the importance of keeping records. Continuous monitorisation by the staff is needed to improve the performance of the residents.