JRSM >
Volume 96, Number 4 >
Pp. 208
Histopathology Department, Queen's Medical Centre, Nottingham NG7
2UH
Department of Colorectal Surgery, John Radcliffe Hospital, Headington,
Oxford OX3 8DU, UK
Dr Rodríguez-Vera and colleagues (November 2002 JRSM1) report that 18 (15%) of 117 clinical histories in a representative sample of case notes from a Spanish general hospital were illegible. Legibility was worse in records from surgical departments.
Another important issue is the manner in which the authors of clinical note entries identify themselves. The lack of a legible name, position and pager number identifying note entries has major implications in large and complex hospital systems where the case notes are an important means of communication between teams from different specialties. At the John Radcliffe Hospital between February and August 2002 we audited how well authors of note entries for patients on the colorectal surgical firm identified themselves, by looking for a legible name, rank and pager number. A total of 540 note entries in 20 patients made in 2002 were compared with 480 note entries made between 1995 and 1999 for the same group of patients. In the earlier series a legible name, rank and pager number were included in respectively 31%, 29% and 49% of note entries, and this increased to 56%, 49% and 72% in 2002. Although the new figures represent an improvement, they point to persistent deficiencies in the way authors of note entries identify themselves. We therefore support the conclusion of Rodríguez-Vera et al. that clinical notes should become computer based.
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