RT Journal Article
SR Electronic
T1 A review of the documentation in the British Armed Forces electronic patient record following discharge from the Role 3 Hospital in Camp Bastion
JF Journal of the Royal Army Medical Corps
JO J R Army Med Corps
FD British Medical Journal Publishing Group
SP 132
OP 134
DO 10.1136/jramc-2014-000337
VO 161
IS 2
A1 Andrew T Cox
A1 T Linton
A1 J Lentaigne
A1 S Sharma
A1 D Wilson
YR 2015
UL http://militaryhealth.bmj.com/content/161/2/132.abstract
AB Introduction The British Role 3 Hospital in Camp Bastion, Afghanistan, uses a different electronic patient record (EPR) to Defence Primary Health Care and the two cannot directly communicate. Consequently, hospital discharge information is transferred by printed letter to primary care, introducing a step where information can be lost. This study was designed to test the hypothesis that the primary care EPR contained an accurate summary of the secondary care admission. Methods Cross-sectional information on consecutive General Internal Medicine patients at the hospital was collected and compared with the primary care EPR. Results From April 2011 the hospital records of 270 patients were reviewed. 239 primary care records were available for comparison. Of 185 patients discharged back to their unit the EPR of 43.8% contained a comprehensive summary, 23.2% contained the scanned discharge letter and 50.8% contained an account of their hospital admission but not necessarily a comprehensive summary. Of the 54 patients evacuated to the UK, the EPRs of 48.1% contained a summary, 68.1% contained the scanned discharge letter and 75.9% contained some account of their hospital admission. More of the evacuated group had their admission documented in the primary care EPR (p=0.001). Only 56.5% of all primary care records contained some account of the hospital admission. Discussion The primary care record is not a reliable record of operational hospital admission and presents an unrecognised potential patient safety issue. The systems responsible for the transfer of discharge summary data need to be appraised to prevent it continuing. Retrospective action should be considered to rectify this problem in former hospital patients.