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We all make records on a day-to-day basis, from telephone messages to a detailed personal diary. No one’s memory is wholly reliable. Records, whatever form they take, are a useful reminder of a course of events, required actions, steps taken, outcomes and further action. In medicine, good record keeping and management are of paramount importance.
In a clinical context, records are essential and, Good medical practice (2013), outlines your responsibilities. The GMC explains that in providing care, you must keep clear, accurate, and legible records which report the relevant clinical findings, the decisions made, the information given to patients, any drugs or other treatment prescribed and who is making the record and when.
Records should be made straight away or as soon as possible after patient care. Records are primarily intended to support patient care and should authentically represent each and every consultation (including by telephone). Any other function for clinical records is secondary. Examples include protecting the practitioner against future claims or complaints, demonstrating CQC compliance, helping the police, or supporting or denying a patient's claim.
Records should be made straight away or as soon as possible after patient care.
Records of patient consultations are now often held electronically. While entering the notes of a consultation on a computer may ensure they are legible, it also requires care. For example, it is clearly essential that the information must be attributed to the right patient's medical records.
Along with clarity and accuracy, details are also important to remind you, or another member of your team, of your care and management plan. The notes may become important later on, if there is a complaint or claim, which will typically be made months or years after a consultation.
All records need to be kept secure and confidential at all times. Technology is not foolproof and regular back-ups should be made. It is advisable to consider keeping these securely at a different site.
Patients have the right to request access to their records. Make sure that patients know what will happen to the data held about them and that they agree to its processing or disclosure. Under the Data Protection Act 2018, organisations or independent practitioners no longer have to register with the ICO but will need to pay a data protection fee. The fee is calculated on members of staff and turnover for independent practitioners. The ICO has guidance on this.
Clinical records must be kept confidential at all times, including during transfer between sites. It would be important to ensure that anyone who takes records out of the practice - say, to work from home - is aware of confidentiality obligations, for example, the need to avoid inadvertent disclosure of patient’s information to family members or visitors. This would include locking paper records away in a suitable filing cabinet, and ensuring any computer systems are appropriately confidential and secure.
The General Data Protection Regulation (GDPR) introduces a duty to report personal data breaches, for example, loss or data or confidentiality breach within 72 hours. There are stiff penalties for personal data breaches.
There is no longer a specific statutory provision covering the retention of private medical records. The Records Management Code of Practice for Health and Social Care (Information Governance Alliance, 2016), Records Management: NHS Code of Practice (Scotland) (Scottish Government, 2012), Welsh Health Circular (2000) 71: For The Record (National Assembly for Wales) and Good Management, Good Records (Department of Health, Social Services and Public Safety, last updated March 2015) all include schedules of minimum retention periods for different types of records. Claims do sometimes arise after these timescales, so ideally all records should be reviewed before they are destroyed, and it would be prudent to keep any patient records where there has been an adverse incident or complaint, until you know it is concluded.
Disposal should be carried out in such a way that protects patient confidentiality, for example, by shredding paper records. Computer-held records may be difficult to delete entirely from a hard drive and appropriate IT advice should be sought.
You may be able to read your own handwriting but can anyone else? Will you always be available to translate that indecipherable squiggle? Most records will now be computerised but there may still be occasions when you will need to handwrite patient records and if so, take a little extra time and care to write legibly.
The delay between an incident and notification of a claim could potentially be several years. If handwriting records, your dated and timed notes will be invaluable in clarifying the sequence of events during your treatment of the patient, as by that time it is unlikely you will be able to remember clearly what happened. With electronic records, the time and date is automatically stored on the computer's hard drive.
What does PID mean? Prolapsed intervertebral disc or pelvic inflammatory disease? It may be clear to you but could be ambiguous. If you must use abbreviations, limit them to those approved in your workplace.
Tampering with records has led to GMC investigations. Clinical notes should be made at the time of treatment or as soon as possible afterwards. If a new finding demonstrates that a previous entry in the notes is factually incorrect, for example, an entry has been made in the wrong patient's records, then the amendment must make this clear. As a rule of thumb, errors should be scored out with a single line so the original text is still legible and the corrected entry written alongside with the date, time and your signature. Any new additions should be separately dated, timed and signed by the doctor who made them. Never try to insert new notes. It might appear easy to alter computer records, but computerised record systems have an audit trail that will allow alterations to be discovered.
Offensive, personal or humorous comments are unprofessional, often misunderstood and could damage your credibility. Remember, patients have a right to access their records and a flippant remark in a patient's notes might be difficult to explain to a judge or Medical Practitioners Tribunal Service (MPTS) Fitness to Practise Panel.
Typed letters and notes have the advantage of legibility, but do have problems of their own. Letters dictated and then typed up later by a secretary may contain errors due to problems with the quality of recording or simple misunderstandings of medical terminology. They should be checked, corrected and signed by the doctor who dictated them.
If you are using typewritten records, you may wish to make a contemporaneous handwritten note as well - these can be invaluable if the patient needs to be seen again before the notes are typed up or if the record of your dictation is accidentally lost.
You will need to see, evaluate and initial every report or letter before it is filed in the patient's records. Most results come through electronically now, so care should be taken to record abnormal findings in the clinical records and document any appropriate action.
All patients have the right to access their medical records and this right is defined in the General Data Protection Regulation (GDPR) and Data Protection Act 2018 (DPA 2018), which allows patients to receive a copy of their records, subject to exceptions.
This page was correct at publication on . Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.
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