Subject(s)
Drug Packaging , Foreign Bodies/complications , Peritonitis/etiology , Acute Disease , Aged, 80 and over , Female , Foreign Bodies/diagnostic imaging , Humans , Intestinal Perforation/diagnostic imaging , Intestinal Perforation/etiology , Intestinal Perforation/pathology , Intestinal Perforation/surgery , Peritonitis/diagnostic imaging , Peritonitis/pathology , Peritonitis/surgery , RadiographyABSTRACT
BACKGROUND: Comprehensive, high-quality medical records are necessary for the communication between health care professionals. We wanted to assess the quality of records on critically ill patients in a teaching hospital in relation to statutory requirements and official guidelines. MATERIAL AND METHODS: We assessed the medical records on 119 patients who died in the hospital upon discharge from its intensive care unit over the 1999 to March 2002 period: the frequency of entries, entries about withdrawal or withholding of therapy, and the quality of the documentation. RESULTS AND INTERPRETATION: The records were of variable and frequently unacceptable quality. We found several violations of statutory requirements; in several wards this was standard practice. The records of four patients were missing. For 84 % of the patients, therapy had been withdrawn or withhold; 58 % of these cases were insufficiently documented. Eighteen patients had only one entry in their record; seven patients had none, in spite of the fact that they had had long stays in hospital. We find this lack of documentation disturbing, as this is a group of patients in whom even small fluctuations in medical status may have serious effects.
