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A post-implementation audit of Douglas Inquiry recommendations for medical record structure
1Patient Information Management Services, Women's and Children's Health Service, Perth, Western Australia. kavia.cheng@health.wa.gov.au
Summary
Staff compliance with new medical records structure at King Edward Memorial Hospital for Women (KEMH) was audited. Issues included poor understanding of instructions and incorrect filing, necessitating staff education and revised procedures.
Area of Science:
- Health Services Research
- Medical Record Management
- Hospital Administration
Background:
- Reforms to medical records structure at King Edward Memorial Hospital for Women (KEMH) followed the Douglas Inquiry.
- An audit was conducted to assess staff adherence to the new medical record system.
Purpose of the Study:
- To investigate staff compliance with the revised medical records structure at KEMH.
- To identify challenges and issues associated with the new filing sequence and dividers.
Main Methods:
- Audit of randomly selected medical records (inpatient/outpatient episodes).
- Analysis of medical record components: correspondence, emergency, outpatient, inpatient, diagnostics.
- Interviews with clinical and clerical staff at KEMH for feedback.
Main Results:
- Identified a lack of staff understanding regarding operational instructions.
- Observed incorrect filing procedures and inappropriate use of dividers.
- Gathered general feedback from clinical and clerical staff.
Conclusions:
- Recommended revision of medical record forms and operational instructions.
- Emphasized the need for comprehensive staff education and a new results/reports signing process.
- Suggested creating a sample medical record for staff reference.
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