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Background - Digitized (scanned) medical records have been seen as a means forhospitals to reduce costs and improve access to records. However, clinical usability of digitized records can potentially have negative effects on productivity.Methods - Data were collected during follow-up outpatient consultations in two NHS hospitals by non-clinical observers using a work sampling approach in which predefined categories of clinician time usage were specified. Quantitative data was analysed using two-way ANOVA models and the Mann-Whitney U test. A focus group was held with clinicians to qualitatively explore their experiences using digitized medical records. The quantitative and qualitative results were synthesized.Results - 406 consultations were observed. Using paper records, there was a significant difference in consultation times between hospitals (p=0.016) and a significant difference in consultation times between specialties within hospitals (p=0.003). Using digitized records there was a significant difference in consultation times between specialties within a hospital (p=0.001). Excluding outliers, there was no significant difference between consultation times using digitized records compared with consultations using paper records in the same hospital, either at site (p>=0.285) or specialty level (p>=0.122). With digitized records at site A, two out of three specialties showed a significant increase in time spent searching computer records (pConclusions - Digitized medical records can be implemented without detrimentaloperational impact. Inherent differences between specialties can outweigh thedifferences between paper and digitized records. Clear and consistent operational processes are vital for the reliability and usability of digitized medical records. Divergent views about usability (such as whether patient summary information is better or worse) may reflect familiarity with features of the digitized record.

INTRODUCTION: Quality assurance of medical record keeping in general surgery is facilitated by use of the CRABEL Score. Critical appraisal and constant feedback to staff plays an important part in improving case-note quality. MATERIALS AND METHODS: For each case-note audit, a house officer reviewed two sets of case notes for each of six consultant surgeons. Scores were awarded according to initial clerking, subsequent entries, consent, and discharge summary. Overall scores were derived by subtracting deductions for omissions in each category from a starting score of 100. A larger number of points deducted due to absent data leads to a lower overall score and indicates poorer quality case notes. After four audits, a clerking proforma specifically designed to address some of the common areas of weakness identified in our record keeping was introduced and a further audit was performed in March 2004 to assess its impact. RESULTS: The mean score was lowest in the September 2001 audit and improved over the next two audits. However, there was a small reduction in September 2003 compared to September 2002. When the individual sections of the score were looked at separately, the greatest contribution to a poor score comes from the 'subsequent entries' section since there are five entries scored individually leading to a cumulative effect on the overall score. Within both the 'initial clerking' and 'subsequent entries' sections, early audits showed poor performance across a range of areas but consistent poor implementation of the guidelines was seen in a small number of specific areas as record keeping improved. The quality of medical notes improved over the first three cycles but the improvement was not maintained subsequently. DISCUSSION: The CRABEL score has been shown to be a useful, reproducible and easy-to-perform objective assessment of the quality of medical record keeping. Repeated audit cycles have ensured that case-note quality remains a high priority and have also led to the development of standardised admission documentation. Introduction of the latter has led to a measurable improvement in medical record keeping.

Renal-cell carcinoma (RCC) during pregnancy is rare. Laparoscopic nephrectomy has been used effectively and safely in nonpregnant patients with RCC. We report a case of a 34-year-old pregnant woman with RCC, which we believe to be the first such case to be managed by laparoscopic nephrectomy.

I read with interest the comprehensive review by Fawdry et al.1 Many of the issues resonate with management of general hospital notes, while some are specific to maternity notes. Recent advances in management of records offer some glimmer of hope. The authors say “paperless” offices benefit only those “logged on in one place for most of the time”. Session mobility is now being delivered in the clinical environment – this allows a session to be suspended on a given PC (free to be used by others) and to be opened again seamlessly on another PC.2 Secondly, many believe that a slavish transition to fully electronic data will lose some of the narrative and richness inherent in the paper record. We have scanned 750,000 volumes of general hospital and 70,000 maternity records, and both are now available to view electronically. Although not structured, this allows colleagues to view records simultaneously across sites and to seamlessly view data from other specialties relevant to the care of the patient. Finally, Portsmouth have implemented a digital pen solution allowing hand written forms to be completed at the ante-natal contact, data to be transferred securely via Blackberry and then entered into the maternity system at the hospital Trust.3 The ability to continue to produce and store images of paper using Document Management Systems appears to be gathering traction for preserving the richness of complex records. Fawdry et al. clearly speak with authority on the absence of standardization in maternity records. Standards for records in secondary care have been produced, but these are not widely implemented.4 In their absence, a more pragmatic approach to electronic patient records is developing using scanned records, session mobility and novel data collection. Informed discussion on these issues is more crucial than ever.

The conflicting pressures created by Achieving a Balance, the new deal on junior doctors’ hours, and the Calman report on specialist training all impinge on the quality of life that consultants can expect in the future, but the immediate impact is on junior hospital doctors. Concern has recently been expressed about the difficulties of introducing 72 hour limits by December 1994. In addition to these direct changes the impact of the internal market and the purchaser and provider divide could lead to large numbers of dissatisfied and demoralised junior doctors. Indeed, a recent survey suggests that up to half of doctors have considered leaving medicine. Perhaps the most frustrating part of a junior doctor's life is the belief that you have no control over events which shape hospital life and even your future career prospects. But my recent experience as a higher surgical trainee at Pinderfields Hospitals NHS Trust in Wakefield, Yorkshire, has prompted me to write this account. Within a short time of arriving it was apparent that there were considerable problems with accommodation, catering, postgraduate teaching, and hours of work. Indeed, the regional task force had described conditions as among the worst in Yorkshire. …