Diane Baylis, Clinical Risk Educator at Medical Protection, looks at why record keeping is vital during the COVID-19 pandemic.
Everyone in healthcare has been working and continues to work in uniquely challenging circumstances during the current pandemic. GPs have had to significantly alter how they work in order to maintain patient services and minimise the risk to staff and others of contracting the virus. This rapid change to new ways of working, including embracing new technology, has enabled patients to continue to access essential health services at a time when the pandemic has severely restricted patients’ ability to see their doctor. As a result, remote consultations have become routine in general practice and out-of-hours centres.
During such rapid change, it is vital to ensure that your medical records fully reflect the context, clinical issues and problems encountered. Documentation must be clear and accurate about the circumstances and the basis in which decisions have been made.
In the event of a complaint or a clinical negligence claim, which could be many months or years after the event, would your medical records stand up to challenge? All healthcare clinicians should be familiar with the professional guidance on good record keeping and the need for this is greater now, perhaps more than ever.
Your record-keeping responsibilities
Doctors have a professional responsibility in relation to record-keeping. The Irish Medical Council's Guide to Professional Conduct and Ethics (2016)states: “You must keep accurate and up-to-date patient records either on paper or in electronic form.”
Ensuring that your records are accurate and up to date can be particularly challenging during the current pandemic, with all the additional workload, as well as being confronted with these new ways of working.
Additional demands with recording clinical records during this pandemic may include:
- Staff shortages and increased clinical demands leading to more pressure on time
- Locum or new staff being unfamiliar with the working environment or specific electronic patient record systems
- Staff needing to receive training to ensure that they are conveying the possible options to patients correctly
- Staff working under stressful and physically uncomfortable conditions, who may be susceptible to errors in record keeping
- Challenges with internet connectivity
What makes a good medical record?
Medical records serve many purposes, including continuity of care, audit, research and quality improvement. All patients’ records should provide a clear account of a particular episode of care: a comprehensive and concise record of what has occurred. A good clinical record contains enough clinical information to enable another clinician to easily take over the patient’s care and understand the possible diagnosis, investigations and treatment recommended or provided.
It is also important to be aware that the patient can request access to their medical records at any time and would expect to see all relevant details about their care.
Good medical records include:
- Patient history
- Examination; positive and negative findings, vital signs and measurements, chaperone details where appropriate
- Diagnosis and investigations; diagnosis or problem, progress or change if it is a review, results of investigations or planned investigations
- Management and treatment; proposed treatment plan or medications prescribed, details of referrals and future management options
- Patient involvement; information given, such as options and risks, benefits discussed, advice and recommendations and decisions jointly made, and consent and agreed patient responsibilities, plus important questions answered
- Follow up and safety netting.
Top tips for keeping good medical records during COVID-19
Remember the minimum standards: context, consent, history and assessment – including examinations and observations, options based on diagnosis, safety netting and follow up. You need to be able to demonstrate that satisfactory assessment and decision making has taken place.
When consulting remotely ensure that you have access to the medical records and provide context to the consultation in your documentation. Ensure the documentation reflects that this is a remote consultation and be specific about how information was obtained. Therefore, documenting that it was “a remote triage/consultation during COVID-19 pandemic”. You can use copy and paste or use an embedded template or macro with this information already contained.
Check the patient’s identity and document that it has been confirmed. Do this by confirming the full name, date of birth and first line of address. You can copy and paste “Patient identity checked and confirmed” or use a template or macro.
When consulting remotely establish the reason why this is a remote consultation instead of face-to-face. Ensure the patient understands the need for a remote consultation and agrees to this. Then document that the patient has consented to the remote consultation. You should inform the patient of any limitations of clinical assessment by remote consultation.
Do not record the video or audio of the consultation unless there is a justifiable reason to do so and there is informed consent from the patient. You should document these discussions and decisions in the clinical record, as decision making must be transparent. Any recording must be stored as part of the medical record.
Document your clinical reasoning and why you reached a certain diagnosis, performed a test or prescribed a medication.
Safety-netting: always give clear safety netting advice, explaining the signs of things getting worse, and what to do in that event. Be specific. Tell them what you would expect to happen if all goes well, when you would be worried (e.g. too breathless to talk, unable to keep down fluids) and what to do in that situation. Offer written back up if possible – you can text a link or email an information leaflet.
If texting or emailing a patient, ensure this message is saved in the medical record. Also save a copy of any letters to the patient, e.g. if any mask or face covering exemption letters are written.
Consider using note templates or macros to save time when writing your medical records and don’t forget to personalise your notes.
All healthcare professionals have a professional obligation to keep accurate, contemporaneous medical records. Good medical records are a vital component of proving high quality, safe patient care and they are often viewed as a reflection of the standard of care that was provided.
Adopting a structured approach to record keeping and incorporating these points will help to ensure that your documentation is maintained at a high standard and is as accurate as possible, therefore ensuring patient safety and also helping to protect you against future claims and complaints.