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Doctors “don’t have access to full medical records”

22 May 2008

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Doctors are seeing hundreds of thousands of NHS patients a year without having access to their full medical records, an investigation has revealed.

A total of 49 NHS trusts responded to the Health Service Journal’s (HSJ) request for details under the Freedom of Information Act.

The study found that there was no standardised way for measuring how many patient records are missing each year.

Some trusts gave a full account of their last audit, while others gave details of the percentage of patients seen without their full records.

The analysis involved a total of two million outpatient appointments across the 49 trusts between 2006 and 2008. It revealed that around 54,000 appointments took place without the patients’ full records.

The HSJ said that if that rate was replicated across the NHS, around 1.2 million outpatients in England are being seen without their notes every year.

Trusts may also downplay the extent of missing records, for example by cancelling appointments where full details are not available or by creating temporary records, it reported.

The HSJ found that six out of 49 trusts had 5% or more notes missing. On average, 2.6% of outpatient records were missing.

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Health Service Journal