Retrieval of casenotes following admission - how the delay affects patient management

The Trust has recently released a policy document concerning the medical risks of treating patients without access to medical records. This states: ‘The Trust will support a consultant who proceeds if he is comfortable that he is performing the correct procedure on the correct patient. Similarly, we will support any consultant who does not proceed in the absence of casenotes because he or she is uncomfortable about the clinical risk.’ This audit was undertaken around the time that this policy was released and examines the very real problems and dangers associated with out-of-hours clinical practice. The authors are a consultant surgeon and her trainee at Furness General Hospital (FGH).