RESUMO
Following the Douglas Inquiry into medical practices and processes, a number of reforms were made to the medical records structure at the King Edward Memorial Hospital for Women (KEMH) in Perth, Western Australia. An audit was undertaken to investigate staff compliance with the new medical record structure, and to identify significant issues arising from the new filing sequence and dividers. The medical record components (correspondence, emergency, outpatient, inpatient and diagnostics) were analysed through random selection of records with recent inpatient and/or outpatient episodes. Interviews with both clinical and clerical staff at KEMH were also conducted to gather general feedback. The main issues identified in the study were a lack of understanding of the operational instructions by staff, incorrect filing procedure, and allocation of inappropriate dividers. The following recommendations were developed to address these issues: revision of all medical record forms (in particular unauthorised medical record forms); education of both clinical and clerical staff; expansion of the operational instructions into a comprehensive guide for staff; development of a new process for signing any results or reports; and compilation of a sample medical record as a reference for staff.
