Royal Devon and Exeter Hospital staff failed to keep full 'med' notes
Bosses at a Devon hospital have admitted they were “disappointed” after health watchdogs found staff had failed to make proper notes in medical records including “do not resuscitate” orders, writes Petra Mann.
In November the Care Quality Commission (CQC) inspected the Royal Devon and Exeter (RD&E).
A report released this week revealed concern around notes kept on consent and treatment, quality assurance and records.
Although patients were asked for their consent prior to treatment, some records showed the hospital did not always act in accordance with legal requirements in relation to ‘do not attempt resuscitation’ orders.
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This meant “inappropriate action could be taken that did not align with patient’s wishes or in their best interests” according to the report.
A spokesman for the CQC said: “Generally, the trust had an effective system to assess and monitor quality of service. However, in relation to ‘do not attempt resuscitation’ decisions and theatre safety checks the audit process was not fully effective or recorded to ensure that all checks were made.
“Overall, patients experienced care, treatment and support that met their needs and protected their rights.”
Melanie Holley, head of governance at RD&E, said: “We were delighted that during their visit, the inspectors were completely satisfied with the quality and standard of the care we offer.
“On this occasion, the inspectors found three areas in which they felt we needed to take action – all of them around documentation.
“Striking the balance between providing hands-on care and documenting it as it happens is a constant challenge for our staff.
“We are disappointed that the inspectors found cases where individuals had not kept proper notes.
“Clearly this is not acceptable and we have plans in place to address this.
“For example, we have communicated with our medical staff, from consultant level down, the importance of completing the ‘treatment escalation plan’ form to record their discussions with patients and relatives.
“We have also introduced a new checklist for topics that must be covered during surgical team briefings.
“We will be carrying out spot checks and audits to ensure staff are aware of their responsibilities and comply with the guidance.”