Admission medical records made at night time have the same quality as day and evening time records

Introduction

A thorough and accurate admission medical record is an important tool in ensuring patient safety during the hospital stay. Surgeons’ performance might be affected during night shifts due to sleep deprivation. The aim of the study was to assess the quality of admission medical records during day, evening and night time.

Material and methods

A total of 1,000 admission medical records were collected from 2009 to 2013 based equally on four diagnoses: mechanical bowel obstruction, appendicitis, gallstone disease and gastrointestinal bleeding. The records were reviewed for errors by a pre-defined checklist based on Danish standards for admission medical records. The time of dictation for the medical record was registered.

Results

A total of 1,183 errors were found in 778 admission medical records made during day- and evening time, and 322 errors in 222 admission medical records from night time shifts. No significant overall difference in error was found in the admission medical records when day and evening values were compared to night values. Subgroup analyses made for all four diagnoses showed no difference in day and evening values compared with night time values.

Conclusion

Night time deterioration was not seen in the quality of the medical records.

Trial registration

Not relevant.

Funding

The study was supported financially by the Tryg Foundation Denmark and The Danish Medical Association.

Correspondence: Ilda Amirian. E-mail: iamirian@gmail.com

Conflicts of interest: Disclosure forms provided by the authors are available with the full text of this article at www.danmedj.dk

Reference: Dan Med J 2014;61(7):A4868