The scene

A hospital consultant contacted the MDU for advice about using electronic records. The hospital where she was working was trying to move to a paperless electronic system, whereby all clinics would be carried out without paper records.

She was concerned as the system had not yet been fully implemented and not all the previous records had been uploaded onto the database. She was being asked to see patients and make clinical decisions in clinic without access to all past clinical records, which she felt might contain potentially relevant medical information that would influence her decision making.

MDU advice

The MDU adviser confirmed that the GMC guidance does say that in providing care, doctors must take account of a patient's history and check that the care or treatment provided is compatible with any other treatments the patient is receiving.

The GMC guidance also says that if patients are at risk because of inadequate resources, policies or systems, you should put the matter right if possible and raise a concern to the appropriate person or organisation.

The adviser suggested the doctor speak to her line manager and clinical director to make them aware of the situation and her concerns, and follow up the conversations with an email.

In the interim, the adviser suggested the member could propose that until the system is fully implemented, patients are seen with their paper records as well. Another alternative might be that if the doctor saw a patient who she didn't consider she could manage without access to their complete medical record, she could ask the patient to re-attend or review the records when available, before again discussing with them a clear management plan as to the way forward.

The outcome

The consultant spoke to and emailed the outpatient manager and also the clinical director about her concerns. It transpired that those concerns were also shared by her colleagues. The hospital management team agreed to continue to make paper notes available for the clinics until such time as the transfer to electronic records had been completed.

Inadequate records

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