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
- Laboratory reports
- Imaging records, including x-rays
- Video and other recordings
- Printouts from monitoring equipment.
The Medical Council states in its publication, A Guide to Ethical Conduct and Behaviour (2009) that:
"You have a duty to maintain accurate and up-to-date patient records either in a manual or electronic form. You are expected to be aware of your obligations under the Data Protection Acts in relation to secure storage and eventual disposal of such records as well as relevant published Codes of Practice." (23.1)
Patients have a right to access their own medical records under current Irish Data Protection and Freedom of Information legislation, on the condition that doing so will not compromise their health or the health of others. Inadequate records that fail to address the key issues will create a poor impression, particularly if they include inappropriate subjective comments about the patient.
Additions or alterations
If you need to delete something from a patient’s medical record, you should put a thin line through the incorrect entry in pen. Insert the date and your initials, and make a note of the reason for the alteration. The original note must not be overwritten and should still be legible, so no one can accuse you of trying to pass off the amended entry as contemporaneous.
Patients have the right, under the Data Protection (Amendment) Act (2003), to ask for factual inaccuracies in the record to be rectified or deleted. The Act does not, however, give them the right to ask for entries expressing professional opinions to be changed. You should only comply with a request if you are satisfied that it is valid – ie, the entry is indeed factually inaccurate – but if you decide that a correction is not warranted, you should still annotate the disputed entry with the patient’s view.
If you decide that the request is valid, add a signed and dated supplementary note to correct the inaccuracy and make it clear that the correction is being made at the patient’s request. Avoid deleting the original entry, though. If the patient demands nothing less than deletion, refer him/her to the Information Commissioner, who will then assess the validity of the request and, if necessary, order the deletion.
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 secondhand 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.