Record keeping
Legible notes must be kept primarily to assist the patient when receiving treatment. But, secondly, should there be any future litigation against your hospital the notes will form the basis of the hospital’s defence. Notes are a reflection of the quality of care given so get into the habit of writing comprehensive and contemporaneous notes.
Adequate records enable you or somebody else to reconstruct the essential parts of each patient contact without reference to memory, a colleague should be able to carry on where you left off.
Should there be any future litigation against your hospital the notes will form the basis of the hospital’s defence
Survival tips
- Remember that confidential information includes a patient’s name and address.
- A breach of confidentiality may be justifiable when a doctor’s duty to society overrides their duty to the individual patient and it is deemed to be in the public interest. For example when there is a threat of serious harm to the patient or others. Before breaching confidentiality, always consider obtaining consent. Take advice from senior colleagues.
- Disclosure of patient information may be required by law, for example to comply with infectious disease regulations. The courts can also require doctors to disclose information, although it would be a good idea to contact MPS if you find yourself presented with a court order.
- Patient information remains confidential even after death. Consider the purpose behind any request for disclosure and the possible effect on the reputation of the deceased.
- Patient privacy should be maintained at all times, accidental disclosure of confidential information should not occur. High-risk areas where breaches can occur are lifts, canteens, computers, printers, wards, A&E departments, pubs and restaurants. Be careful not to leave memory sticks or handover sheets lying around.
- Patient information should be held securely and in compliance with data protection legislation.
Scenario
Dr P is working in a medical ward when she sees Mrs G, a patient referred from A&E, after she suddenly collapsed. She takes a comprehensive history, and does a complete examination. Dr P then notices that some blood samples were taken from her in A&E, and checks on the results server on the hospital intranet. She finds out that the samples “have clotted” and new samples need to be sent. The phlebotomists are quite busy, but they agree that they’ll do it as soon as possible.
During the handover she doesn’t tell the next doctor that the blood results need checking
Dr P finishes her shift by writing the history, examination findings and results, she also writes “bloods”, followed by a tick, meaning that they have been sent. During the handover she doesn’t tell the next doctor that the blood results need checking.
Mrs G becomes unwell within the next few hours, and the registrar on duty comes to see her. He is reassured by the notes that recent blood results were normal, and checks on the results server himself. It is only at this stage, that it is discovered that the patient is severely anaemic.
Dr P failed to ensure that the documentation was clear indicating what had, and what had not been done. Luckily Mrs G came to no harm.