Hospital records: records or a science of disease

Abstract

The findings of an attempted retrospective study of medical records of 1,107 patients admitted to the University Teaching Hospital during a two year period have been elaborated. As a result of a poor filing system only 734 case notes could be traced. Of the latter, due to inadequate and inefficient clinical entries into the files only 369 files were found to contain enough information which could have formed a basis for any meaningful clinical study. The importance of medical records had been stressed. It has been suggested that a clinician's responsibility does not end merely by being involved in the medical care of a patient. A physician should ensure proper entry of the daily events into the file, as well as feel responsible for the way hospital records are filed.