Quick guide to medical records

Clinical records contain sensitive personal data, contributed to by a number of clinicians over a varying period of time. Keeping them secure from prying eyes or inadvertent disclosure is a legal as well as a professional responsibility

Why keep records?

The GMC expects GPs to keep clear and accurate notes detailing the relevant findings, the decisions made, the information shared, any drugs prescribed and other investigations, at the same time as the events you are recording or as soon as possible afterwards.¹

You are professionally obliged to keep good records. In the event of a complaint, clinical negligence claim or disciplinary proceedings, the medical record will contain the factual base for your defence. Cases can be difficult to defend if information is missing, inaccurate or indecipherable.

What makes good clinical records?

Good records will contain all the information one clinician will need to take over where another left off; they should be clear, objective, contemporaneous, attributable and original. The mnemonic SOAP is a useful reminder of the content that should be included: 

• Subjective – what the patient says 
• Objective – what you detect – examination and test results 
• Assessment – your conclusions – often differential diagnosis 
• Problem list and plan – management and follow up.

Be wary of using abbreviations that can be misinterpreted. Derogatory terms and comments have no place in clinical records.

Ways to avoid problems when handling records?

• Obtain a patient’s consent and record it, before disclosing information to a third party. 
• On rare occasions it may be necessary to disclose information either without consent or if the patient declines their consent. In such circumstances you should be able to justify the disclosure, if called upon to do so. 
• Make patients aware that their information will be shared among health professionals on a “need-to-know” basis. 
• Ensure that each practice in which you work in has a data controller under the provisions of the DPA (1998). 
• Be conscious of inadvertent breaches of confidentiality, eg, talking loudly in a reception area, checking that the information you send by fax will be received in a secure place, etc. 
• Do not leave records lying around.

When is disclosure of information acceptable?

• If information is disclosed to insurance companies, employers and people involved in legal proceedings, it must be limited to the authority provided by the patient. 
• A doctor must not disclose personal information to a third party, such as a solicitor, without the patient’s express consent. There is also an obligation to inform the patient whose personal information is being sought.
• If a court orders you to disclose health records you should comply with the request; but it would be reasonable to raise objections if the court is seeking to compel the disclosure of irrelevant information.²
• Where GPs have a statutory duty to report certain information, eg, notification of births, deaths, infectious diseases, certain terminations of pregnancy – without obtaining consent. 
• The police have no more right to access confidential information than anyone else, except under the following circumstances: 
  • under road traffic legislation, where they may need the name and address of somebody 
  • the patient has given consent to release the information 
  • in compliance with a court order 
  • in a case when consent is not obtainable or declined, the public interest in disclosing the information outweighs the public interest in preserving it. Specifically if it is to protect individuals or society from risks of serious harm.

When is disclosure more complicated?

The GMC recommends obtaining consent before using patients’ histories or photographs for education and training, although this is currently undergoing consultation. When it is necessary to use patient identifiable information, or it is not practicable to anonymise it, you should seek patients’ consent.

Discussing information with relatives can be problematic. In general, information should be given to the patient who can share it with their family. Drivers have a legal obligation to inform the DVLA if diagnosed with a medical condition that could impair their fitness to drive. If they refuse, the GMC advises ddoctors to contact the DVLA and inform the patient that they have done so.³

In circumstances where you think a child is at risk, their best interests are paramount. This may require disclosure to social services or even the police. Consent should be obtained from the parents where possible, except in cases where this would put the child at risk.

References

1. GMC, Good Medical Practice (2006), para 3f and g
2. GMC, Confidentiality (2009) para 21–22
3. DVLA, At a Glance Guide to the Current Medical Standards of Fitness to Drive (September 2007).