Hospital medical records: The unit file in current use

The "explosion" of scientific information in the last 3 decades has revolutionised medical and surgical treatment, but has, at the same time, increasingly strained the facilities of both medical scientific libraries and medical records departments. Patterns of illness have changed, and the case papers of individual patients now frequently relate to illnesses which last for many years. Unit files are becoming so bulky that their contents can neither be easily physically stored nor mentally assimilated. More patients and more knowledge about their illnesses result in more clerical work in wards and clinics, and this in turn slows the flow of infomation throughout the hospital. In Chapter 1 the present situation is outlined, and it is suggested that major faults exist in the present system of making and keeping medical records. In Chapter 2 the term "operational research" is explained; application of this technique to problems of medical records is discussed. It is suggested that altering work routine may often be the best way of solving specific record problems, and that the facilities for making and keeping good medical records are the same as those necessary for good patient care, A model is described by means of which any hospital Unit may be surveyed in detail to define faults in the existing record system. Two medical and two surgical Units are surveyed in detail in Chapter 3 to illustrate the application of this model and to indicate common faults in present-day British hospitals. Some of these faults are discussed in more detail in Chapter 4 and an E.C.G. and an X-Hay department are surveyed to illustrate some of the problems of ancillary departments. In Chapter 5 the arguments for and against centralising typing services are considered in detail, together with the question of how best to organise the non-typing duties of a secretary. It is concluded that Unit secretaries are too valuable members of clinical teams to be satisfactorily replaced by typing "pools". The methods available for transporting documents are reviewed in Chapter 6 and it is concluded that, because in the forseeable future "handraulic" methods (Payne, I966) will continue to be used, adequate internal messenger services should be organised in all large hospitals. Some of the problems in making and handling laboratory records are considered in Chapter 7 by reference to a detailed survey of a radio-isotopes department. In Chapter 8 the traditional systems of drug prescribing, administration and stock control in hospital wards are described and criticised. Two existing new systems are considered in detail: these involve drastic alteration of work routine and recording, and it is suggested that they should, together, be widely adopted. An attempt is made in Chapter 9 to answer the classical question "what is meant by a good medical record?" It is concluded that, because a record is a means of communication, its efficiency as such is an index of its quality. Standardisation of format is discussed at some length in Chapter 10, both in general terms and in relation to specific documents, and it is pointed out that many of the problems of keeping case papers tidy in a unit file depend not on page format but on the binding mechanism used. future trends in administrative organisation and electronic equipment are reviewed in Chapter 11, and the potentials of computer-assisted diagnosis briefly discussed. Finally, in Chapter 12 it is concluded that present working conditions in many British hospitals are seriously prejudicing the making and keeping of good medical records, and that only detailed operational research can provide the necessary information about what exactly is at fault and what remedial measures should be taken