84 Emergency General Surgery medical records standards at a tertiary referral hospital: Lessons learned from Royal College of Physicians

Abstract

Abstract Introduction The record keeping standards published by the Royal College of Physicians (RCP) aimed to maximize patient safety, quality of care, support professional best practice and assist compliance with Information Governance and NHS Litigation Authority. We aimed to study the medical records keeping in emergency general surgery admissions at a London tertiary hospital. Methods A randomized retrospective analysis of 30 patients was performed in a period from 1st May 2022 to 1st August 2022. Results of the first cycle were presented at a local meeting, followed by action plans and recommendations. A teaching session has been delivered for junior doctors about the RCP standards and planned to be delivered every 4 months for all new staff members. A closing loop has been carried with same methodology and number of emergency surgical admissions from 1st November 2022 to 22nd of November 2022. Results Good standards of records keeping in the first cycle was reached in 8 (100%) out of the 12 RCP criteria, with multiple areas that needed improvement. In the closing loop, a significant improvement was reached: discharge letters standards with 93.3% compared to 86.7 % in the first cycle, 3.3% records contained information filled in irrelevant section compared to 20%, 10 % of the cases in the second cycle had advanced decisions documentation compared to 0% in the first cycle. Conclusions The maintenance of good medical record keeping requires regular audit and formal education of junior doctors to reach a high standard in emergency surgical admissions according to the RCP record keeping criteria.