Recording essential information

You should take care to include all information that other members of the team will need to continue care of the patient safely

Inadequate medical records are the underlying cause of many failures of communication – the records are the essential tool of communication between members of the multidisciplinary team. Subtle but significant changes may be missed when several different doctors see a patient over many days, unless adequate information is available from previous examinations.

What you include or leave out of the record is a matter of professional judgment, but you should take care to include all information that other members of the team will need to continue care of the patient safely. As months or years may elapse between treatments or illnesses and staff may have changed in the meantime, the records should also serve to reconstruct events at a later date without recourse to memory.

Advice on what to include in the medical record can be found here. For hints on keeping good records, and advice on access to and disclosure of medical records, ask for a copy of the MPS Guide to Medical Records booklet.

Box 12: Sharing care with colleagues

Ensure that colleagues who deputise for you, whether formally or informally, are fully aware of all relevant details of the patients for whom they are responsible. Practices should establish protocols for the transfer of relevant information between doctors who cover for each other, particularly in co-operatives and when deputising services are used.

If it is in the patient’s best interests and you have their implied or express consent, welfare and voluntary agencies and family carers should be given any relevant information.

 

Box 13: Case report

A diabetic clinic in a teaching hospital diagnosed TB in a diabetic patient with a history of weight loss. He was admitted to hospital and, on discharge, was prescribed three months’ supply of ethambutol, rifampicin, pyrazinamide, isoniazid and pyridoxine.

A month later, he was seen in the diabetic clinic but there was no discussion of his TB treatment. He failed to attend his next appointment.

Three months after starting TB treatment, the patient began to complain of deteriorating vision and his GP made an urgent referral to the eye clinic. The GP had not yet received a discharge letter about the patient’s last hospital admission for the treatment of TB, nor had the diabetic clinic informed him of the diagnosis, so his referral letter to the eye clinic made no mention of the fact that the patient was taking ethambutol.

The patient attended the eye clinic several times over a month, but no history of TB or treatment for TB was obtained – his visual loss being attributed to diabetes. However, his vision continued to deteriorate and by the end of this period he was only capable of counting fingers.

A week later, the patient attended the diabetic clinic. Only then was the diagnosis of ethambutol eye toxicity raised. The patient was seen immediately in the eye clinic where the diagnosis was confirmed and the ethambutol stopped, but by then he had sustained a permanent loss of 90 per cent of his vision.

  

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