Cleaning up the paper trail - our clinical notes in open view

Area of Science:

• Healthcare Informatics
• Medical Record Management
• Patient Data Security

Background:

• Physicians have a legal and ethical duty to protect confidential patient information.
• Paper-based healthcare records remain prevalent in Ireland.
• Existing data protection standards for paper records are limited.

Purpose of the Study:

• To assess the protection of paper-based patient records.
• To identify high-risk patient records and assess variations in protection.
• To observe data security during different times of the working week and with varying personnel present.

Main Methods:

• A customized audit tool developed using Sphinx software was employed.
• Data were collected prospectively over three months across all hospital wards.
• Observations included the location of medical record trolleys and the presence of unattended records and personnel.

Main Results:

• Unattended medical records were found on 33% of ward visits, with 49% occurring during weekend hours.
• Nursing records were unattended on 67% of visits, often in groups of six or more.
• Record security was notably weaker when ward secretaries were off duty.

Conclusions:

• Confidential patient information is at significant risk of inappropriate disclosure in Irish hospitals.
• Nursing records require more frequent attention regarding unattended data than medical records.
• Enhanced security measures are crucial, especially during off-peak hours and when support staff are absent.