Record Keeping Standards is a development led by the Royal College
of Physicians of London (RCP) Health Informatics Unit and funded by the National
Health Service (NHS) Connecting for Health. A supplementary report produced
by the RCP makes a number of recommendations based on a study held at an
acute hospital trust. We audited the medical notes and coding to assess the
accuracy, documentation by the junior doctors and also to correlate our findings
with the RCP audit. Northern Lincolnshire & Goole Hospitals NHS Foundation
Trust has 114,000 ‘finished consultant episodes’ per year. A total of 100 consecutive
medical (50) and rheumatology (50) discharges from Diana Princess of Wales
Hospital from August–October 2009 were reviewed. The results showed an
improvement in coding accuracy (10% errors), comparable to the RCP audit but with
5% documentation errors. Physician involvement needs enhancing to improve the
effectiveness and to ensure clinical safety.
