Record keeping
Good record keeping is a recurring theme in many a medicolegal context, as is apparent from this edition’s selection of case reports. Satisfactory medical records are a basic requirement of good medical practice, particularly in a multidisciplinary environment. In addition, good record keeping may provide the evidence required to defend a negligence claim, possibly arising many years after the adverse incident itself.
The GMC make it clear that they expect doctors to “keep clear, accurate, egible and contemporaneous patient records which report the relevant clinical findings, the decisions made, the information given to patients and any drugs or other treatment prescribed”. They emphasise the need for doctors to keep their colleagues well-informed when sharing the care of patients, and of course good medical records fulfil a vital function in that regard.
Not only may a doctor’s standard of care be judged, at least in part, by the quality of his or her record keeping, but it is our experience that a significant proportion of negligence claims are impossible to defend because of illegible, inaccurate or otherwise inadequate record keeping.
It is hard to overemphasise the evidential significance of good clinical records. In particular, it has become increasingly important to document the advice given to patients in respect of the possible risks of any proposed treatment. The term “medical records” encompasses not only traditional handwritten notes, but amongst others computerised records, clinical correspondence, laboratory reports, radiographs, and clinical photographs.
Last year in the UK, MPS dealt with some 2,000 requests for telephone advice on access to medical records. In the same period, some 300 new case files were opened which dealt, at least in part, with medical record issues. MPS advises that records should be clear, objective, contemporaneous, first-hand and tamperproof; they should be kept safe and secure, and retained for the appropriate period.
Doctors should of course be familiar with the legal principles governing access to and disclosure of the records that they hold; they should also be aware of any relevant national or local codes of practice. In this regard, the NHS has recently published a records management code of practice, intended as a guide for those working within or under contract to NHS organisations in England. As usual, if in doubt about a medical records issue, seek assistance from an appropriate colleague, or an MPS medicolegal adviser.
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