More than two-thirds of patients who see a doctor at the Floriana health centre are not given their medical record, resulting in poor continuity of care, according to a pilot study.
On visiting a health centre for a consultation with a GP, patients provide their identity card at reception where healthcare assistants hand them their medical record to give to the doctor during the visit.
But only 23 per cent of the 411 patients who visited a GP at the centre over four weekdays picked at random last September, were provided with a medical record.
This emerged during a pilot study published in the Malta Medical Journal entitled ‘Continuity of information and care – a pilot study in a health centre’.
Authors Michelle Bugeja and Jurgen Abela point out the Maltese healthcare system does not allow patients to register with one GP in the healthcare system.
Patients are seen each time by a different doctor and this emphasises the importance of keeping good medical records to ensure proper continuity of care between one doctor and another.
“Patients’ medical records are basic clinical tools that should be used in every consultation since they guide providers to the delivery of consistent care tailored for the individual patient,” the authors wrote.
Their study aimed to assess continuity of care at the centre by looking at the percentage of patients who were given their medical records.
They did this by spending four weekdays and a Sunday observing the system at the Floriana health centre in September.
During these five days, doctors saw 529 patients (411 during the weekdays and 118 on Sunday). Only 23 per cent of patients who attended during weekdays were given the record while the number increased to about 36 per cent on Sunday. Fewer records were handed out during the afternoons possibly due to the fact that this was when healthcare assistants went out for their lunch break.
Patients’ medical records are basic clinical tools that should be used in every consultation
A closer look at the medical records used during consultations showed that in the majority of cases – 75 per cent – doctors updated them.
However, about 37 per cent did not insert a legible signature, making it difficult to identify them in future and none filled in the time of the consultation.
Such details were important if medico-legal issues arose later. The authors make a range of recommendations, including educating healthcare assistants and patients about the importance of the records and having efficient guidelines on filing systems.
They also suggest increasing the space available on the records on which to write because, currently, GPs have to document their notes within very limited space. Another suggestion is by investing in electronic records.
In the absence of such developments, the authors say, another option to enhance continuity of care would be to increase the number of visits by appointment allowing for records to be made available beforehand.