Why keep clinical records?

In the event of a complaint, claim or disciplinary proceedings, the doctor’s defence will depend upon the evidence available in the clinical records

The main purpose of any clinical record is to provide continuity of care, but medical records are also used for other purposes:

  • Administrative and managerial decision-making within the NHS.
  • Meeting current legal requirements, including enabling patients to access their records.
  • Assisting in clinical audit.
  • Supporting improvements in clinical effectiveness through research.
  • Providing the necessary factual base for responding to complaints and clinical negligence claims.

The GMC expects doctors to “keep clear, accurate and legible records, reporting the relevant findings, the decisions made, the information given to patients, and any drugs prescribed or other investigation or treatment” and to “make records at the same time as the events you are recording or as soon as possible afterwards”.1

In general, clinical records that contain sufficient information to secure continuity of care will also contain the information required for all other purposes.

In the event of a complaint, clinical negligence claim or disciplinary proceedings, the doctor’s defence will in large part depend upon the evidence available in the clinical records. If essential information is missing, found to be inaccurate or indecipherable, cases may be lost when they could otherwise have been won. Where possible, information used for non-clinical purposes should be anonymised (cf Caldicott principles).

Case 1

At six months old, a boy suffered with diarrhoea and vomiting. His GP was called and treatment provided at home. Due to severe dehydration, he became both physically and mentally handicapped. When he was in his twenties, a solicitor suggested investigating the circumstances surrounding the illness and a claim of negligence arose. By this time, the GP had died, leaving only minimal scant medical records of his consultations. In the absence of any robust evidence to the contrary, the claim against the doctor’s estate had to be settled.

  

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