Robust record keeping is vital to patient safety, quality of
care and the demands of clinical governance. Inadequate medical
records mean that some litigation claims cannot be properly
defended and need to be settled out of court. Inadequate medical
record keeping is a regular part of many fitness to practise cases
heard by the GMC, and is often highlighted as a criticism in
inquiries and inquests.
The purpose of this article is to look at some of the key issues
that health professionals need to be familiar with in order to
properly fulfil their duties to patients and to protect themselves
and their employer.
What are records?
All records created during a patient’s journey through the NHS
forms part of their health record. They contain a broad range of
material such as computer records and handwritten notes, laboratory
reports and correspondence between health professionals. Together
they are factual contemporaneous evidence of a decision and how it
has come to be made. They may be used as evidence in a variety of
forums, and may need to be read and understood not only by other
health colleagues and the patient, but also potentially by the
patients’ family, police, lawyers, judges, coroners, inquiry panels
and professional bodies.
Purpose of record keeping
Some of the main purposes of good record keeping are:
- Patient care - Comprehensive informative health records
facilitate communication between all relevant parties, continuity
and quality of care, and an understanding of the clinical history
of a patient.
- Complaints, inquiries and litigation – Often the medical notes
are one of the means by which a healthcare professional is judged
and good notes will protect and assist the medical team,
demonstrate appropriate risk assessment, and give them credibility
in the event of criticism. Remember that if there is a dispute
about events then often if it is not recorded it didn’t
- Audit –. The clinical and cost effectiveness of care can be
assessed by auditing the outcome of the care.
- Research national data sets and morbidity registers.
- Outside agencies - Other agencies can use good medical records
eg insurance etc for risk assessment
What do good clinical records look like?
- All patient clinical contact and key interactions should be
recorded in black permanent ink legibly, simply and
- Every entry should be dated, timed and legibly signed with your
name and position. A stamp can be helpful to ensure that the
name and position is clearly recorded.
- Notes should be informative, complete and up to date.
Record clinical history, normal and abnormal findings, discussions,
investigations, results, drugs prescribed, decisions made, care
plan, referrals, special or risk factors. Do not record things that
you did not do.
- If a mistake is made or notes need to be altered it should be
crossed through with a single line. The date and name of the person
who has amended the notes should then be recorded. Remember that
computer records will have an audit trail that will enable
alterations to be identified.
- The patient and any other parties at a meeting should be
clearly identified together with a precise note of the date and
- Notes should be in chronological order and ideally should be
contemporaneous. Contemporaneous notes are given more weight than
those made subsequently.
- Ensure that records show how patients are being involved in
- Record information shared with others and why.
- Correct clinical coding of diagnoses helps electronic audit and
- Nicknames should not be used
- Abbreviations should not be used unless widely accepted
- No jargon, offensive or gratuitous comments should be
- Score blank pages through.
- Records should be stored confidentially.
- Take care when entering notes on a computer that the
information is going on to the correct patient’s medical
How Bevan Brittan can help
Our healthcare team has a wealth of experience in providing
legal support to healthcare professionals who need support in
drafting or reviewing a policy or providing training to staff on
good record keeping. If you would like to discuss any of the issues
raised in this article please contact us.