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An essential guide to medical records

Post date: 04/07/2017 | Time to read article: 8 mins

The information within this article was correct at the time of publishing. Last updated 14/11/2018

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This Essential Guide was produced as a resource for Medical Protection members in the UK. It is intended as general guidance only.

Medical Protection members are always welcome to telephone our medicolegal advice line for more specific practical advice and support with medicolegal issues that may arise. Alternatively, members may  submit a medicolegal query online.
Click here to go to our medicolegal advice page.


Download guide as a PDF
Last updated: April 2017

Introduction

Good clinical records are a prerequisite of delivering high-quality, evidence-based healthcare, particularly where a number of different clinicians are contributing simultaneously to patient care. Unless everyone involved in clinical management has access to the information they require, duplication of work, delays and mistakes are inevitable. Records may be held electronically or manually, or a mixture of both.

The main purpose of any clinical record is to provide continuity of care, but medical records are also used for other purposes: 

  • Administrative and managerial decision-making within the NHS.
  • Meeting current legal requirements, including enabling patients to access their records.
  • Assisting in clinical audit.
  • Supporting improvements in clinical effectiveness through research.
  • Providing the necessary factual base for responding to complaints and clinical negligence claims.

In the event of a complaint, clinical negligence claim or disciplinary proceedings, the doctor’s defence will in large part depend upon the evidence available in the clinical records. If essential information is missing, found to be inaccurate or indecipherable, cases may be lost when they could otherwise have been won.

Clinical records include a wide variety of documents generated on, or on behalf of, all the health professionals involved in patient care. This includes:

  • Handwritten clinical notes
  • Computerised/electronic clinical records
  • Emails
  • Scanned records
  • Text messages (both outgoing from the NHS/professional and incoming from patients)
  • Correspondence between health professionals
  • Laboratory results
  • X-ray films and other imaging records
  • Photographs
  • Videos and audio recordings
  • Printouts from monitoring equipment, particularly in anaesthesia and obstetrics, A&E and ICU
  • Consent forms.

What makes good clinical records?

Medical records – whether handwritten or electronic – are essential to allow continuity of care for your patients. Good record keeping means you or a colleague can reconstruct the key parts of each patient contact without relying on memory.

Good clinical records are important in delivering high quality healthcare, particularly when a number of different clinicians are involved in patient care at the same time. Unless everyone involved in clinical management has access to the information they require, duplication of work, delays and mistakes are inevitable.

Clear and detailed records are also important in providing a factual base necessary for responding to complaints and claims, and for production of legal reports. A lack of clear documentation can make defence of a claim, for example, very difficult. Poor record keeping could also attract criticism by the Singapore Medical Council.

The SMC [1] cites the following requirements for medical notes:

  1. Medical records kept by doctors shall be clear, accurate, legible and shall be made at the time that a consultation takes place, or not long afterwards.
  2. Medical records shall be of sufficient detail so that any other doctor reading them would be able to take over the management of a case. All clinical details, investigation results, discussion of treatment options, informed consents and treatment by drugs or procedures should be documented.

Good clinical records will be well executed in terms of both content and presentation. You may wish to consider the following information regarding content and presentation when preparing medical records for your patients.

Content

  • Relevant medical history
  • Examination and other relevant clinical findings – include important positives and negatives and details of objective measurements such as blood pressure.
  • Differential diagnosis
  • Investigations – details of any investigations requested.
  • Treatment – details of drugs, doses, amount prescribed, and any other treatment organised (include the batch number and expiry date of any medications personally administered).
  • Capacity and consent – details of the patient’s capacity to consent (or lack of) and their consent to proposed investigations, treatments or procedures. Details also of all treatment options discussed (including not receiving treatment), the benefits and risks of each option and any questions that were asked by the patient.
  • Referrals and follow-up – arrangements that have been made for follow-up tests, future appointments and referrals. Include any ‘safety-netting’ advice given to the patient about when to seek more urgent review.

Presentation

  • Clearly written – good clinical records will be understandable when handwritten. Each entry should also be legibly signed with the date and time.
  • Objective – it is important that clinical records are factual and free of subjective opinion about patients or their relatives. You should always assume that patients will read their notes at some point.
  • Contemporaneous – you should write up clinical records as soon as possible after the consultation in order to ensure accuracy and clarity.
  • Attributable – if any information has been given to you by anyone other than the patient, you should record who has provided this, as well as what they said.
  • Original – notes should not be retrospectively amended without making clear when the amendments have been made and why. In the event that you have made a factual error, do not obliterate the entry that you wish to correct. Instead, run a single line through it so it can still be read and add the correction including the date and your signature. Failure to do so could lead to allegations of dishonesty, attempting to pass amendments off as part of the original record. Amendments to electronic records can be tracked by audit trail and should be clearly marked on the file.
  • Easy to understand – avoid the use of abbreviations, as unconventional or unfamiliar abbreviations could lead to confusion amongst staff and untoward incidents.

References

  1. SMC Ethical Code and Ethical Guidelines p7

Further reading

Confidentiality

There is a common-law duty to preserve professional confidence

Confidentiality may seem a very straightforward principle, but translating principle into practice can be problematic. There are all sorts of situations where it is difficult to know if patient information should be shared or not – with the police, for example, or Social Services.

Confidentiality is a legal principle and the following should be noted:

  • NHS employees will find a confidentiality clause in their contract
  • There is a common-law duty to preserve professional confidence
  • There are requirements under the Data Protection Act 1998 to keep personal data, including medical records, secure
  • It is a condition of registration to abide by GMC guidance, which includes a requirement to respect patient confidentiality
  • The Information Commissioner can impose a Civil Monetary Penalty on an organisation of a maximum of £500,000 if there is a serious breach of the Data Protection Act and the data controller acted deliberately, or was reckless, and the breach was of a kind likely to cause substantial distress or damages to an individual.
The duty of confidentiality goes beyond undertaking not to divulge confidential information; it includes a responsibility to make sure that written patient information is kept securely. Confidential records should not be left where other people may have casual access to them and information about patients should be sent under private and confidential cover, with appropriate measures to ensure that it does not go astray.

Confidentiality is not an absolute principle – there are several exceptions, and these are listed below. You can find more comprehensive information by following the provided links to the relevant GMC guidance.

"The duty of confidentiality goes beyond undertaking not to divulge confidential information; it includes a responsibility to make sure that written patient information is kept securely"

  • Disclosure with patient consent
    GMC, Confidentiality (2009), paras 24-35
  • Disclosure without patient consent
    Information can be disclosed without the patient’s consent in two instances:
    • If required by the law – see GMC, Confidentiality (2009), paras 17-23
    • If it is in the public interest – see GMC, Confidentiality (2009), paras 36-39
  • Members of the clinical team
    GMC, Confidentiality (2009), paras 25-29
  • Publishing case reports, photographs and recordings
    GMC, Making and Using Visual and Audio Recordings of Patients (2011)
  • Relatives
    GMC, Confidentiality (2009), paras 64-66
  • Reports to the DVLA/DVA
    GMC, Confidentiality: Reporting Concerns about Patients to the DVLA or the DVA (2009)
  • Child protection
    GMC, Protecting Children and Young People: the Responsibilities of all Doctors (2012), paras 28-51
    GMC, 0-18 Years: Guidance for All Doctors (2007), paras 42-52
  • Communicable diseases
    GMC, Confidentiality: Disclosing Information about Serious Communicable Diseases (2009)
  • Confidentiality after death
    GMC, Confidentiality (2009), paras 70-72
  • Insurance and employment purposes
    GMC, Confidentiality: Disclosing Information for Insurance, Employment and Similar Purposes(2009)

Retention of medical records

The following national guidelines should be adhered to: Department of Health, Records Management: NHS Code of Practice (2006).

Relevant legislation

You should be familiar with the principles of the following pieces of legislation.

The laws affecting healthcare can be complex; remember that a call to an MPS medicolegal adviser (0800 561 9090) can help to clarify any areas of uncertainty.

  • Data Protection Act 1998
  • Access to Medical Reports Act 1988
  • Access to Health Records Act 1990

Cases

Case 1

At six months old, a boy suffered with diarrhoea and vomiting. His GP was called and treatment provided at home. Due to severe dehydration, he became both physically and mentally handicapped. When he was in his 20s, a solicitor suggested investigating the circumstances surrounding the illness and a claim of negligence arose. By this time, the GP had died, leaving only brief medical records of his consultations. In the absence of any robust evidence to the contrary, the claim against the doctor’s estate had to be settled.

Case 2

A 26-year-old single woman went to see her GP complaining of blackouts. He referred her to a neurologist, giving a detailed account of the blackouts but not disclosing the medication she was on, which included the oral contraceptive pill. The neurologist started the patient on anticonvulsants. Three months later she conceived.

Her claim against both doctors succeeded. As the GP had failed to alert the neurologist to the fact the patient was taking the oral contraceptive pill, and the neurologist had not asked about medication, both had been in breach of their duty of care, causing the unwanted pregnancy.

Case 3

A 38-year-old woman phoned her GP surgery complaining of back pain and difficulty passing urine. The GP checked her notes and saw a reference to PID, which he interpreted as pelvic inflammatory disease. He concluded that she had another urinary tract infection and wrote a prescription for antibiotics for the patient to collect.

In fact PID referred to her recurring problems with a prolapsed intervertebral disc which had now given rise to a cauda equina syndrome and associated pain and urinary symptoms.

"In fact PID referred to her recurring problems with a prolapsed intervertebral disc"

Case 4

A 56-year-old man saw a printout of his clinical records in connection with a claim following a road traffic accident. He was surprised to see in his records a reference to the local GUM clinic and asked that this be removed. Further investigation confirmed that he had never been to a GUM clinic so the record was clearly incorrect.

The computerised record was amended with a note stating that the relevant data was deleted by his GP on the basis of it being inaccurate; the archived paper records were retrieved and the reference to the GUM clinic blocked out in black ink with a signed and dated note explaining that an incorrect entry had been deleted. 

Case 5

Following a road traffic accident, a patient claimed compensation for a whiplash injury.

Her insurers requested a report from her GP, but the patient exercised her right under the Access to Medical Reports Act 1988 to view the report before it was despatched.

"Unhappy with its contents, she asked the GP to change it. He declined, saying that it was factually accurate and the details given were relevant so it was inappropriate for him to make the requested alterations."

Unhappy with its contents, she asked the GP to change it. He declined, saying that it was factually accurate and the details given were relevant so it was inappropriate for him to make the requested alterations. He explained that her options were:

  
  •  (a)  to refuse to allow the report to be sent to the insurance company,
  •  (b)  to allow the report to be sent but to add a statement of her own to it, or
  •  (c),  to allow the report to be sent as it was

Case 6

Following a young man’s sudden death, his insurance company sought information from his GP, relying on a declaration giving authority during the patient’s lifetime for his medical details to be divulged. The GP was not satisfied with this, and asked the insurance company to obtain the consent of the executors to the estate, making it clear that, until this was available, he was not obliged to supply the report.

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