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. Clinical records should include:
- Relevant clinical findings
- The decisions made and the actions agreed, and who is making the decisions and agreeing the actions
- The information given to patients
- Any drugs prescribed or other investigation or treatment
- Who is making the record and when.
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 present, and any instance in which the patient has refused to be examined or comply with treatment. It is also important to record your opinion at the time regarding, for example, diagnosis.
Medical records 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
- Text or email communication with patients.
The NHS’s National Information Standard for End of Life Care Co-ordination Record Keeping Guidance identifies the key information that should be held in an end of life care record.
In addition, you should include referral or follow-up arrangements and, in particular, warnings you may have given patients about requirements for ongoing monitoring, or the consequences of not accepting particular treatments.
Patients have a right of access to their own medical records under the Data Protection Act 1998 (DPA). For access to records by a third party, see Access to Health Records factsheet. If a complaint or claim arises, the records are likely to be examined closely by experts, administrators, lawyers and the courts. Inadequate records that fail to address the key issues will create a poor impression.
The GMC’s view
The GMC’s Good Medical Practice dictates that the documents you make, including clinical findings, to formally record your work must be clear, accurate and legible. You should make records at the same time as the events you are recording or as soon as possible afterwards.
You must keep records that contain personal information about patients, colleagues or others securely, and in line with any data protection requirements.
Additions or alterations
If you need to add something to a medical record or make a correction, make sure you enter the date of the amendment and include your name, so no one can accuse you of trying to pass off the amended entry as contemporaneous. Do not obliterate an entry that you wish to correct – run a single line through it so it can still be read.
Exception: Patients who hold a Gender Reassignment Certificate have the right to insist that all reference to their previous gender be obliterated from their records.
Patients have the right, under the Data Protection Act (DPA), 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, then this should be done in exceptional cases – and only then in paper records, never electronic. This must be discussed fully with the patient.