Keeping clear, accurate and contemporaneous patient records is a prime responsibility of all medical practitioners.
Patient records make effective healthcare possible. They document treatment and outcomes, and in a medico-legal context, they serve to demonstrate professional integrity and justify what you did.
It is little wonder then, that when patients complain or make a claim, your medical records - how accurate and sensitive they are, and how you kept them - can come under intense scrutiny.
Make them robust enough to withstand that scrutiny, particularly as patients now have rights to access paper and electronic records.
Document patient care
For clinical reasons, medical records should fully document the progress of a patient's care, recording all decisions taken and the evidence on which those decisions were based.
To ensure good continuity of care, they should clearly communicate this information to anyone who might have future contact with the patient.
For legal reasons, good and accurate record keeping may prove invaluable in responding to and defending against a complaint or claim.
When it comes to a claim of negligence, contemporaneous records of all decisions made about a patient's care - and the justifications behind those decisions - are essential.
Often accurate, legible and complete notes and other records are the only defence. Memory may, understandably, be incomplete.
A good medical record should be comprehensive and accessible, legible and pinned to a particular date. What you record may vary, but good note taking is essential.
Key information should include:
- History: as it applies to the condition and relevant past history including concurrent illnesses, medications and allergies.
- Examination of the patient: include positive and relevant negative findings, and record all pertinent observations and measurements (e.g. pulse, temperature, BP).
- Diagnosis: record this clearly and concisely, justifying how the conclusion was reached and recording any uncertainties or differentials.
- Investigations: including lab results and imaging such as X-rays or scans.
- Management: record drugs prescribed and administered with dosage, and other treatments, such as physiotherapy.
- Follow up and referral: include details of follow-up tests, future appointments and referrals.
- Patient information: include details of discussions regarding risk-benefit, treatment plan, prognosis and potential complications.
- Consent: record consent given, ensuring that it take into account the above.
If this sounds onerous, bear in mind that not all of these points are applicable to every consultation, or even every patient.
From a legal point of view, good patient notes can be like a watertight alibi. They can stop a medico-legal claim in its tracks. Forensically, good patient records answer fundamental questions:
- Who? All notes in the record should identify the patient (name, date of birth, hospital number if relevant, address) and clearly identify the doctor making the note, along with a signature to verify this, in written records.
- When? Notes should record the date and time when a patient was seen or when a test or other procedure was undertaken, or a treatment given. They should also note when the actual record or note was made if there has been a significant time lapse (hours or days - in which case, detail the reasons for delay).
- What? Record what was done, said, instructed, observed, checked.
- Why? It is important to justify in the notes decisions taken with regard to patient care.
However good your memory is, it may not be reliable. Also in a legal context, good patient records are always more valuable than memory.
Think how many patients you see in a session, week or year. Unless it was particularly rare or traumatic, you will not be able to recall the detailed circumstances of any single case.
Good notes corroborate evidence given in court and will enhance your credibility.
Finally, do bear in mind that patient access to medical records is enshrined in law. The Data Protection Act 1998 applies UK-wide to all data about identifiable, living individuals.
In the context of medical practice, it covers patient records held on computer or in paper files, and extends to handwritten notes and X-rays.
Under the Act a patient has a right of access to see personal information and to have it corrected if it is wrong.
- Dr Fernie is head of medical division, Medical and Dental Defence Union of Scotland.
- This topic falls under section 3.1 of the RCGP curriculum 'Clinical Governance'.
1. Medical records should fully document the progress of a patient's care.
2. Notes must be legible and dated.
3. Include details of the patient's history, examination, investigations and diagnosis.
4. Remember, a patient has a right to access personal information and to have it corrected if it is wrong.