[Medical records of critically ill patients]

Comprehensive, high-quality medical records are necessary for the communication between health care professionals. We wanted to assess the quality of records on critically ill patients in a teaching hospital in relation to statutory requirements and official guidelines.

We assessed the medical records on 119 patients who died in the hospital upon discharge from its intensive care unit over the 1999 to March 2002 period: the frequency of entries, entries about withdrawal or withholding of therapy, and the quality of the documentation.

The records were of variable and frequently unacceptable quality. We found several violations of statutory requirements; in several wards this was standard practice. The records of four patients were missing. For 84 % of the patients, therapy had been withdrawn or withhold; 58 % of these cases were insufficiently documented. Eighteen patients had only one entry in their record; seven patients had none, in spite of the fact that they had had long stays in hospital. We find this lack of documentation disturbing, as this is a group of patients in whom even small fluctuations in medical status may have serious effects.