Keeping good medical records is essential for continuity of care, especially when many clinicians are involved in a patient’s care. Good record keeping is an integral part of good professional practice.
- Records should include sufficient detail for someone else to take over a patient’s care, seamlessly, from where you left off.
- Records that ensure continuity of care will also be adequate for evidential purposes, in the event of a complaint, claim or disciplinary action.
- Medical records should be clear, objective, contemporaneous, tamper-proof and original.
- Abbreviations, if used, must be unambiguous and understood by all members of the healthcare team.
- Medical records comprise handwritten and computerised notes, correspondence between health professionals, laboratory reports, x-ray and other imaging records, clinical photographs, videos and other recordings, and printouts from monitoring equipment.
- Medical records are sensitive personal data and must be kept securely to prevent damage and unauthorised access.
- Medical records can usually be shared with other members of the clinical team responsible for clinical management, unless the patient objects.
- Access to records or the information they contain is also permissible in other circumstances but the record holder must always be prepared to justify disclosure.
- Where information from medical records is required for audit and research purposes, consent should be taken from the data subject to process the information for that purpose.
- Any alteration to medical records should be patently apparent to avoid any accusation that there has been an attempt to mislead or deceive.
- Common problems are illegibility of handwritten notes, failing to date and sign them, inaccurate recording of information or insufficient detail.