Medical records - Which path will you take

Medical records: Which path will you take?

MPS medicolegal adviser Dr Sonya McCullough and Gareth Gillespie show how the course of your career can hinge on your record-keeping

It is, perhaps, easy to be flippant about a medical record.

You may think of it as a bureaucratic sideline to the buzz and unpredictability of practising medicine; a tiresome, superfluous chore that is carried out to keep the suits in the Medical Council happy.

But to underestimate or disregard altogether the importance of keeping good medical records is to potentially deal a severely damaging blow to your career.

To underestimate the importance of keeping good medical records is to potentially deal a severely damaging blow to your career

Whether you have received a complaint or a claim for clinical negligence, or you are at an inquest, the presence of a complete, up-to-date and accurate medical record can make all the difference to the outcome.

In this article, we have drawn on three real MPS cases in Ireland (with some facts altered to preserve confidentiality) to demonstrate how good record-keeping can shape your professional future.

Case 1: No informed consent

Miss A was referred to Mrs B, consultant gynaecologist, with a diagnosis of ovarian cancer. Mrs B, in that initial consultation, explained that she would admit Miss A for a course of chemotherapy. She gave Miss A some indication of the prognosis but did not elaborate.

Consent should be informed to be valid and medicine has moved away from a paternalistic to an autonomous approach

Miss A made a complaint to the Medical Council, saying that she had received no information about alternative regimens of treatment and there had been no discussion about future fertility or prognosis. Mrs B had not kept a record of the consultation and could not recollect much of what had been said.

Learning points

Patients are better informed in the era of advances in IT and they wish to have adequate information on which to base their decisions. Consent should be informed to be valid and medicine has moved away from a paternalistic to an autonomous approach.
Mrs B had not recorded her decisions or conversation during the consultation, thus making it difficult to assist her in providing a robust response to the letter of complaint to the Medical Council.
Good record-keeping is essential during vital consultations in a patient’s management, where important decisions are being made about the patient’s care.

Case 2: Relevant negatives

Mr F attended his GP, Dr L. He had noted a chest discomfort over the last two days, eased by antacids. Dr L asked him about type, duration and radiation of the pain, and about precipitating factors and relieving factors.

This did not reflect the care and attention paid to the patient during the consultation or support and justify his decision on management, making the case more difficult to defend

He recalls asking him about shortness of breath and cardiac risk factors. However, he did not record these relevant negatives in the notes. Given that the history did not indicate a cardiac aetiology, Dr L prescribed further antacids and asked the patient to attend for review in one week, sooner if his symptoms did not settle. The patient died subsequent to a myocardial infarct three days later.

His widow made a complaint to the Medical Council and the matter was referred on to a fitness to practise panel.

Learning points

Dr L had actually taken a full history and, based on the negative features for ischaemic heart disease, had diagnosed a gastric cause for the symptoms. However, he had simply written "seems gastric – Rx Gaviscon” in the notes. This did not reflect the care and attention paid to the patient during the consultation or support and justify his decision on management, making the case more difficult to defend when it went before the fitness to practise panel.
In any situation, when there is a differential diagnosis, recording relevant negative findings supports the doctor’s justification for his subsequent management of the patient.

Case 3: Retrospective notes

Mr J was admitted to a psychiatric unit on 2 February 2012. He was seen by the junior doctor, Dr X, on arrival. She took a full psychiatric history, including a discussion about suicidal ideation.

However, she did not record this conversation in the notes. Mr J was discharged from hospital on 6 February 2012 and hanged himself two days later.

Dr X went back to the medical records on 8 February 2012 and, in a different coloured pen, under the entry she had made for 2 February 2012 wrote “no suicidal ideation”

Dr X went back to the medical records on 8 February 2012 and, in a different coloured pen, under the entry she had made for 2 February 2012 wrote “no suicidal ideation” – she made a retrospective note. This was picked up by the coroner during the inquest and the matter was referred to the Medical Council.

This was considered a matter of probity and the Preliminary Proceedings Committee referred the matter to a fitness to practise hearing.

Learning points

All records should be contemporaneous. If you do add to a record, date and sign it and make it clear that you are adding it retrospectively. In the above scenario, Dr X, when she was made aware of what had happened, should simply have made an entry on 8 February 2012 indicating that she was aware of the suicide, and that she recollected that the patient had no suicidal ideation when she clerked him in on 2 February 2012, although she did not record this at the time.

Why are medical records important?

The Medical Council says: “You have a duty to maintain accurate and up-to-date patient records either in manual or electronic form.”¹

The main reason for maintaining medical records is to ensure continuity of care for the patient. They may also be required for legal purposes if, for example, the patient pursues a claim following a road traffic accident or an injury at work. For health professionals, good medical records are vital for defending a complaint or clinical negligence claim; they provide a window on the clinical judgment being exercised at the time.

What are medical records?

This probably sounds like an obvious question. However, medical records cover an array of documents that are generated as a result of patient care. This includes:

Handwritten notes
Computerised records
Correspondence between health professionals
Laboratory reports
Imaging records, including x-rays
Photographs
Video and other recordings
Printouts from monitoring equipment
Text messages
Emails.

The essentials

Good medical records summarise the key details of every patient contact. On the first occasion a patient is seen, records should include:

Relevant details of the history, including important negatives
Examination findings, including important negatives
Differential diagnosis
Details of any investigations requested and any treatment provided
Follow-up arrangements
What you have discussed with the patient. This is particularly important regarding management options and the taking and documentation of consent.

It is also important to record your opinion at the time regarding, for example, diagnosis

On subsequent occasions, you should also note the patient’s progress, findings on examination, monitoring and follow-up arrangements, details of telephone consultations, details about chaperones present, and any instance in which the patient has refused to be examined or comply with treatment. It is also important to record your opinion at the time regarding, for example, diagnosis.

Medical records must be:

Objective recordings of what you have been told or discovered through investigation or examination
Clear and legible
Made contemporaneously, signed and dated
Kept securely.

Abbreviations

The National Hospitals Office Code of Practice for Healthcare Records Management states:

“35. Abbreviations shall not be used. In the event of abbreviations being utilised, only abbreviations approved by the National Hospitals Office may be permitted.

36. All approved abbreviations shall be written in higher case (capital) BLOCK letters and not in a cursive script and/or in lower case.

37. Other than the abbreviations approved by the National Hospitals Office, on each side of each page the full term shall be used, followed by the abbreviation in brackets. Thereafter the abbreviation may be used on that page.

38. Abbreviations shall not be used on documentation which is used for transfer, discharge or external referral letters.

39. Abbreviations shall not be used on consent forms, death certificates, incident report forms and communications sent from the hospital.

Note: Drugs names shall not be abbreviated.”

Be aware, also, that patients may access their records – it is essential that you avoid insulting or derogatory remarks.

Additions or alterations

If you need to add something to a medical record or make a correction, make sure you enter the date of the amendment and include your name, so no-one can accuse you of trying to pass off the amended entry as contemporaneous.

There is only one thing more damaging than absent or poor notes and that is fabricated notes

Do not obliterate an entry that you wish to correct – run a single line through it so it can still be read. Finally, there is only one thing more damaging than absent or poor notes and that is fabricated notes.

Occasionally, when sued, a doctor will forget, or be unaware, that a copy of the records has already been disclosed to the patient’s legal team. When he becomes aware he is to be sued, he reviews his notes and realises that the care or notes are suboptimal and then amends the records. We then prepare a defence based on the records disclosed to us and our case collapses when we compare our “original” records to the claimant’s copy of the true original records – copied before summons was issued.

Keeping good records

You are obliged by the Medical Council to keep good medical records – whether electronic or handwritten – as they are essential for the continuity of care of your patients.

Adequate medical records enable you or somebody else to reconstruct the essential parts of each patient contact without reference to memory. They should, therefore, be comprehensive enough to allow a colleague to carry on where you left off.