Reviewing case record review
- Correspondence to: R McL Wilson Chairman, NSW Council for Quality in Health Care, Royal North Shore Hospital, NSW 2065, Australia; rwilson{at}doh.health.nsw.gov.au
More public discussion is needed on the role and content of the case record
In their paper in this issue of QSHC in which they redesign current case (or medical) record review methods for the purpose of detecting adverse events and teasing out opportunities for preventing recurrence of this patient harm, Woloshynowych et al1 state that “in our view the full potential of retrospective record review has yet to be explored”. Their view on the so far unrealised potential of the medical record is true, despite current efforts in some countries.
The medical record has a time honoured place as a chronological account of the clinical state and care of a particular patient. This place has been reinforced by the routine use of the medical record as part of any legal or insurance inquiry about care, as well as in clinical or peer review processes that are designed to improve the delivery of health care. But, unlike an incident report or computer alert, the medical record has a passive nature that requires and rewards systematic examination after an alerting process identifies the records that need review. That alert may be an adverse clinical outcome—for …
