Good medical records – whether electronic or handwritten – 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.
Why good records are important
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.
In general, records that are adequate for continuity of care are also sufficiently comprehensive for legal use.
Good medical records
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 relevant negatives
- Examination findings, both positive and negative
- Differential diagnosis
- Details of any investigations requested and any treatment provided
- Follow-up arrangements
- What you have told/discussed with the patient.
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 offered and accepted or declined, and any instances in which the patient has provided or refused consent to be examined or treated. 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.
NB Although abbreviations are undoubtedly a great time-saver, you should take care to use them only where their meaning is unambiguous and would be easily understood by your colleagues. Never use abbreviations for making derogatory comments about the patient.
Medical records should contain all the pertinent information about a patient’s care and can cover a wide range of material including:
- Handwritten notes
- Computerised records
- Correspondence between health professionals including email and SMS correspondence.
- Laboratory reports
- Imaging records, including x-rays
- Video and other recordings
- Printouts from monitoring equipment.
The Medical Council states in its Guide to Professional Conduct and Ethics for registered Medical Practitioner 2016 that:
“33.1 Medical records consist of relevant information learned from or about patients. They include
visual and audio recordings and information provided by third parties, such as relatives.
33.2 You must keep accurate and up-to-date patient records either on paper or in electronic
form. Records must be legible and clear and include the author, date and, where appropriate, the time of the entry, using the 24-hour clock.
33.3 If you are working in out-of-hours services or telemedicine, you should make every effort to
ensure that any notes you make about a patient are placed in the patient’s medical record with their general practitioner as soon as possible (see paragraph 43).
33.4 You must comply with data protection and other legislation relating to storage, disposal and access to records. You should understand the eight rules of data protection (see Appendix B).
33.5 Patients have a right to get copies of their medical records except where this is likely to cause serious harm to their physical or mental health. Before giving copies of the records to the patient, you must remove information relating to other people, unless those people have given consent to the disclosure.”
Patients have a right to access their own medical records under the provisions of the Data Protection Act 2018 and Freedom of Information legislation. Of note, Freedom of Information legislation only applies to public patient records. Access can be restricted in limited circumstances including when release of information is likely to cause serious harm to the physical or mental health of the data subject or others.
Rectification and erasure
Under Article 16 of the General Data Protection Regulation (GDPR), a patient has the right to request rectification of patient data which is factually inaccurate. However, this right is not absolute and depends on the circumstances of each case. For example, a patient may disagree with a diagnosis in their records but if this diagnosis was the opinion of their treating clinician at the time, deletion would not be appropriate. In these circumstances, a note should be included in the records stating that the patient disagrees with the entry but the initial entry should not be erased.
Article 17 of the GDPR concerns the right to erasure. Doctors have an ethical requirement to keep accurate records and have a right to defend medico-legal claims therefore the right to erasure is not absolute. Any requests to delete medical records should be examined on a case by case basis and further advice sought.
Recommended minimum retention periods:
- Healthcare records of an adult – eight years after last treatment or death.
- Children and young people – until the patient’s 25th birthday, or 26th if the young person was 17 at the conclusion of treatment, or eight years after the patient’s death. Guidelines for public hospitals also recommend keeping records for longer periods if the contents have relevance to adult conditions or have genetic implications.
- Maternity records – 25 years after the birth of the last child.
- Records of a mentally disordered patient – 20 years after last treatment or eight years after death.
Disposal of records
Clinical records may be transferred to the National Archives rather than be destroyed, if they are of archival value. If records are to be destroyed, paper records should be shredded or incinerated. CDs, DVDs, hard disks and other forms of electronic storage should be overwritten with random data or physically destroyed. Be wary of selling or donating second-hand computers – “deleted” information can often still be recovered from a computer’s hard drive.
If you use an outside contractor to dispose of patient identifiable information, it is crucial that you have a confidentiality agreement in place and that the contractor provides you with certification that the files have been destroyed.
You should keep a register of all healthcare records that have been destroyed or otherwise disposed of.