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Keeping comprehensive and contemporaneous clinical records

Thorough documentation is crucial, not only in the interests of good continuity of care, but also to show (in the event of a claim) the facts on which you based a decision. At MPS we have also seen many cases where the doctor did examine the patient, but either did not document it at all, or did not document the important findings – especially significant negative findings.
Adequate medical records enable you or somebody else to reconstruct the essential parts of each patient contact without reference to memory

Many serious illnesses do not start out as typical presentations but can develop quickly, so a note in the records that a diagnosis was excluded because specific signs or symptoms were absent can provide crucial evidence in defence of a claim in negligence. Examples might be the absence of neck stiffness in a young person with a severe headache and fever, or the absence of muscle guarding in a case of abdominal pain.

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.

Poor-quality medical records are not only a major cause of iatrogenic injuries, they also make it difficult to defend a clinical negligence claim or a Council disciplinary inquiry; it is axiomatic that poor note-keeping is evidence of poor clinical practice. All of the following can compromise patient safety or lead to medicolegal problems:

  • Not recording negative findings.
  • Not recording the substance of discussions about the risks and benefits of proposed treatments.
  • Not recording drug allergies or adverse reactions.
  • Not recording the results of investigations and tests.
  • Illegible entries.
  • Not reading the notes when seeing a patient.
  • Making derogatory comments.
  • Altering notes after the event.
  • Wrong patient/wrong notes.

To be useful, the medical records should contain all the significant information that members of the healthcare team, or future carers, will need in order to be sufficiently informed about the patient’s past and current clinical assessments and treatment and relevant family and social history, lifestyle and beliefs.

The Health Professions Council considers the following as the absolute minimum necessary for each patient’s records:

  • Personal (identifying) particulars of the patient.
  • The bio-psychosocial history of the patient, including allergies and idiosyncrasies.
  • The time, date and place of every consultation.
  • The assessment of the patient’s condition.
  • The proposed clinical management of the patient.
  • The medication and dosage prescribed.
  • Details of referrals to specialists, if any.
  • The patient’s reaction to treatment or medication, including adverse effects.
  • Test results.
  • Imaging investigation results.
  • Information on the times that the patient was booked off from work and the relevant reasons.
  • Written proof of informed consent, where applicable.8
Medical records should contain all the significant information that members of the healthcare team, or future carers, will need

To this we would add, from a medicolegal and risk-management perspective:

  • All important positive and negative findings from the consultation with the patient. Information about the presence or absence of certain signs or symptoms at different stages in the course of a patient’s illness is not only important for forming a picture of the development of the patient’s condition, but can be crucial in defending any future medicolegal challenges.
  • Differential diagnosis, including reasons for ruling out (or preferring) a potential diagnosis.
  • Details of discussions with the patient about the risks and benefits of proposed treatments, including the risks of no treatment, costs and any information given to them in this regard (eg, patient information leaflets).
  • Any advice or warnings given to the patient – not to drive while taking certain medication, for example.
  • Arrangements for follow-up tests, future appointments and referrals made.
  • Any instructions or advice given to the patient. It is particularly important to make a note of any instructions you give to patients about what to do if their symptoms change, persist or worsen, such as returning for another consultation.
Information should be added to the patient’s notes as soon as it becomes available
For the sake of good continuity of care, patients’ records should be kept as up to date as possible, which means that information should be added to the patient’s notes as soon as it becomes available. It is good practice to make a habit of noting information as it arises so that it is not lost if something happens to distract your attention – eg, an emergency, a phone call, or an interruption by a colleague.

Abbreviations

Abbreviations are commonly used in medical records but can be misinterpreted and lead to mistakes in diagnosis or management. So the rule is, when in doubt, write it out – in full. Sarcastic and derogatory abbreviations have no place in medical records – acronyms like FAS (Fat and Stupid) are gratuitously offensive and sure to destroy any therapeutic relationship if the patient discovers their meaning.

Alterations

Once an entry has been made in a medical record, it should not be deleted or obliterated, even if it is later found to be erroneous or misleading. If you need to make a correction, use a single black line to cross out the error and then add the amendment and your signature, name (in block capitals) and the date and time.

Follow-up arrangements

British GP, Roger Neighbour, introduced the notion of “safety-netting” in his 1987 book, The Inner Consultation, and a great many GPs have since incorporated this simple technique into their daily practice. In essence, safety-netting is the art of managing uncertainty by developing the habit of asking yourself three questions and making contingency plans based on the answers.

The three questions are:

  • If I’m right, what do I expect to happen?
  • How will I know if I’m wrong?
  • What would I do then?
Once an entry has been made in a medical record, it should not be deleted or obliterated, even if it is later found to be erroneous or misleading
One of the more obvious – and effective – strategies for dealing with this sort of uncertainty is to tell the patient what sort of changes to look out for (eg, side effects, no improvement, condition worsening, etc) and what to do about them if they occur. It might even be as simple as saying “If it’s no better in ten days, come back and see me”.
You should make a note in the patient’s records about any warnings or instructions you give the patient

On the subject of informing patients about side-effects, sometimes you may need to issue a warning to the patient. For example, a patient taking warfarin should be warned not to take St John’s Wort, which is known to interact with warfarin. Patients should also be warned not to drive or use machinery when taking drugs that cause drowsiness.

You should make a note in the patient’s records about any warnings or instructions you give the patient.