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 happen!
  • 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 accurately.
  • 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 time.
  • 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 their care.
  • Record information shared with others and why.
  • Correct clinical coding of diagnoses helps electronic audit and patient follow-up.
  • Nicknames should not be used
  • Abbreviations should not be used unless widely accepted
  • No jargon, offensive or gratuitous comments should be made.
  • 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 records.

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.

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