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Missing Clinical Information in NHS hospital outpatient clinics: prevalence, causes and effects on patient care by Susan J Burnett; Vashist Deelchand; Dean Bryony Franklin; Krishna Moorthy; Charles Vincent is a Health Professions article available to read on EtoBox.

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## Background In Britain over 39,000 reports were received by the National Patient Safety Agency relating to failures in documentation in 2007 and the UK Health Services Journal estimated in 2008 that over a million hospital outpatient visits each year might take place without the full record available. Despite these high numbers, the impact of missing clinical information has not been investigated for hospital outpatients in the UK. Studies in primary care in the USA have found 13.6% of patient consultations have missing clinical information, with this adversely affecting care in about half of cases, and in Australia 1.8% of medical errors were found to be due to the unavailability of clinical information. Our objectives were to assess the frequency, nature and potential impact on patient care of missing clinical information in NHS hospital outpatients and to assess the principal causes. This is the first study to present such figures for the UK and the first to look at how clinicians respond, including the associated impact on patient care. ## Methods Prospective descriptive study of missing information reported by surgeons, supplemented by interviews on the causes. Data were col

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Author

Susan J Burnett; Vashist Deelchand; Dean Bryony Franklin; Krishna Moorthy; Charles Vincent

Publisher

BioMed Central; Springer (Biomed Central Ltd.); London: BioMed Central, 2001-; Springer Science and Business Media LLC; Society for Mining, Metallurgy and Exploration Inc. (ISSN 1472-6963)

Published

2011

Language

EN

Field

Health Professions (Health Sciences)