12 record keeping tips

Medical records are a key part of a doctor’s responsibilities when it comes to providing good patient care.

Records include electronic documents, hand-written notes, voice recordings, emails, consent forms, text messages, laboratory results, photographs, videos and printouts.

Record keeping is a topic we talk about a lot. But there is a reason for that. If you don’t have the evidence to show what’s happened with a patient, it is more difficult to protect and defend your professional position if a complaint or claim arises.

At every step of your career, it’s crucial that you record your conversations with patients and colleagues, the diagnosis you make, all treatment plans you decide upon, and any post-operative care and communication that takes places.

Making a list and checking it twice

1. All your records need to be clear, accurate and legible. They should be dated and detailed, and made at the time of the consultation or as soon as possible afterwards.
2. Clinical records should include relevant clinical findings, the decisions made and actions agreed, the information given to patients, the drugs prescribed or other investigation or treatment. Consent for examination and the offer, presence or refusal of a chaperone should also be recorded. They should also include the identity of the person making the record and the date.
3. If for any reason you share a patient’s information without obtaining their consent, you must make a record of your reasons for doing so. You must document your reasons for disclosing information without consent and any steps you have taken to seek consent, to inform them about the disclosure, or your reasons for not doing so.
4. All medical records should be documented in a clear structured manner to ensure continuity of care.
5. Remember that records you make may at some point be read by the patient or in some circumstances their family.
6. Any refusal of consent to treatment or advanced decisions to refuse resuscitation must be very clearly recorded in the patient’s notes.
7. If for any reason you make a retrospective entry in a patient’s record it should be clearly dated to reflect the date the entry was made.
8. Patients have the right to access to their medical records under the General Data Protection Regulations.
9. Patients have a right to request that factual inaccuracies in their records be corrected. If they do not agree with an entry which is a matter of professional opinion it is important to highlight the issue the patient has challenged and why.
10. Retention of medical records should be in line with the Retention Schedule as set out in the Records Management Code of Practice for Health and Social Care 2016. Generally this is 10 years after the patient’s death but some exceptions apply.
11. Before any records are destroyed, they should be reviewed as the retention periods are the minimum required and a decision should be made as to whether it is appropriate to destroy them or not. Where there has been a complaint or claim arising from the care which is ongoing, the records should be retained until the matter is concluded. .
12. Accurate and clear records are the cornerstone of any medicolegal defence – make sure to follow these tips as part of your day to day practice.

If you have any questions or need any further advice on record keeping, please get in touch on 0800 561 9090 or visit medicalprotection.org.