Keeping good clinical records is an important duty for the whole practice team. Kate Taylor, Clinical Risk Education Manager, examines why and provides tips for clinicians on how to do so.
Read this article to:
- Discover why keeping good clinical records is important
- Find out why we often don’t keep good clinical records
- Learn what makes a good clinical record
Many clinicians are aware that their clinical entries aren’t always what they should be – a point brought sharply into focus when they are asked to explain the assessment and management of a patient, long after the consultation took place. We cannot always rely on our memories to recall a particular consultation or episode of care. Maintaining complete contemporaneous records can provide evidence of care given and can prove invaluable in defending a complaint or claim. The GMC in Good Medical Practice and the Nursing and Midwifery Council professional standards both clearly outline your professional responsibilities in relation to record keeping – it is an integral part of practice and is essential to the provision of safe and effective care. Keeping good clinical records is essential for continuity of care, especially when there are many clinicians involved in delivering care.
Good records, good defence, poor records, poor defence
In the event of a complaint or claim, medical and nursing records are likely to be examined closely by experts, administrators, lawyers and the courts. Patients also have a right of access to their own medical records under the Data Protection Act 1998, so what impression would your records give about your care delivery to patients? Studies indicate that the quality of a practitioner’s record keeping can be seen as a direct reflection of their approach to and standard of professional practice.1 Put simply, where a nurse always maintains neat, accurate and contemporaneous records it is very likely that they will adopt the same meticulous approach to their nursing practice.
What is a medical record
The medical record should contain all the pertinent information about a patient’s care and may cover a wide range of material including:
- handwritten and computer generated clinical notes • letters to and from other health professionals
- laboratory reports
- X-rays
- printouts from monitoring equipment, for example ECG recordings incident reports and statements
- photographs
- videos
- tape recordings of telephone conversations
- communication with patients and other healthcare professionals regarding the patient’s care, for example text messages, emails and other messages.
What makes a good record?
A good record will contain enough information to enable another clinician to easily take over the patient’s care and understand the possible diagnosis, investigations, and treatment recommended or provided. The record should include:
- patient history
- examination
- positive findings
- negative findings
- vital signs and measurements
- use of a chaperone where appropriate
- diagnosis and investigations
- diagnosis or problem
- progress or change if it is a review consultation
- results of investigations
- planned investigations
- plan – management and treatment
- proposed management plan
- medication(s) prescribed
- details of referral(s)
- future management options
- information – patient involvement
- information given
- options and risks/benefits discussed
- advice and recommendations
- decisions jointly made and consent
- agreed patient responsibilities
- important questions answered
- follow-up arrangement and safety net advice.
Why might we not keep good records?
One reason why good records aren’t kept is time pressure. It may be a difficult balance between how much to write in the notes and how much time you may have available. What you include or leave out of the medical record is a matter of professional judgment, but you should include all information that other members of the team would need to continue care of the patient safely. Visits, advice (including telephone advice), medication given and allergies should all be recorded.
Other reasons often cited for poor record keeping include viewing the task as a chore, being too busy and seeing too many patients, distractions and interruptions, being a poor typist, feeling it is unlikely you will receive a claim and being set in a certain way of doing things.
References
- Fraser J. Keeping midwives out of court. The Practising Midwife 2010;13:36-7.