Medical records - An MPS guide
Summary
Clinical records should be clear, objective, contemporaneous, tamper-proof and original
- Keeping good clinical records is essential for continuity of care, especially when many clinicians are involved in delivering care. Good record keeping is an integral part of good medical practice.
- Records should include sufficient detail for someone else to take over a patient’s care, seamlessly, from where you left off.
- Records that secure continuity of care will also be adequate for evidential purposes,in the event of a complaint, claim or disciplinary action.
- Clinical records should be clear, objective, contemporaneous, tamper-proof and original.
- Abbreviations, if used, must be unambiguous and universally understood.
- Clinical records comprise handwritten and computerised notes, correspondence between health professionals, laboratory reports, x-ray and other imaging records, clinical photographs, videos and other recordings, and printouts from monitoring equipment.
- Clinical records are sensitive personal data and must be kept securely to prevent damage and unauthorised access.
- Clinical records can usually be shared with other members of the clinical teams responsible for clinical management, unless the patient objects.
- Access to records or the information they contain is also permissible in other circumstances but the record holder must always be prepared to justify disclosure.
- All healthcare organisations holding clinical records must be registered (under the Data Protection Act) with the Information Commissioner.
- Where information from clinical records is required for audit and research purposes, anonymised data should be used wherever possible.
- Records should not be kept indefinitely but should be retained as long as they are relevant to patient care and associated legal and administrative purposes.
- Any alteration to written medical records should be immediately apparent to avoid any accusation that there has been an attempt to mislead or deceive.
- Similarly, with electronic records, any entries should be made clear to identify any changes.
- Common problems are illegibility of handwritten notes, failing to date and sign them, inaccurate recording of information and insufficient detail.
Important
Due to the dynamic nature of medicolegal law, we suggest that you visit these pages of our website frequently to access the most up-to-date information.