Medical Practitioners Act 2007: the increased medical record burden.
New medical record keeping obligations are implemented by the Medical Practitioners Act (2007), effective July 2009. This audit, comprising review of 347 medical entries in 257 charts on one day, investigated compliance with the Act together with the general standard of medical record keeping. The Medical Council requirement was absent all but 3 (0.9%) of entries; there was no unique identifier or signature in 28 (8%) and 135 (39%) of entries respectively. The case for change is discussed.
Byrne
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GEMS Directorate, St James's Hospital, Dublin 8. declangbyrne@gmail.com
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KL
O'Connor
C
C
Walsh
J
J
Silke
B
B
D005568:Forms and Records Control / Q000331:legislation & jurisprudence* / Q000592:standards; D019983:Guideline Adherence; D006801:Humans; D007494:Ireland; D008499:Medical Records / Q000331:legislation & jurisprudence* / Q000592:standards; D011786:Quality Control