Keeping accurate contemporaneous notes is a key part of good record keeping. It helps maintain good continuity of care for the patient, and it puts the doctor in the best possible situation to respond if faced with a complaint or claim.
There are many circumstances, however, where it's simply not possible to enter data into records at the time they're made. For example:
- if an IT system crashes
- at a consultation with a temporary resident
- at an out-of-hours home visit, or other unexpected consultation.
To avoid the medico-legal pitfalls of consulting without notes, we offer the following advice.
- If you're unfamiliar with a patient's medical history, it's especially important to take a detailed history, including asking the patient if they have any drug allergies.
- Make a contemporaneous paper note immediately after seeing the patient and transfer this to the computer records as soon as possible.
- Make sure written notes are legible, include the time and date of the consultation, and are signed with an identifiable signature.
- Manual systems should be used uniformly by practice staff and accessible to all members of the healthcare team.
- If a computer entry is made retrospectively, it's helpful to document the source of information, eg 'entry typed from handwritten note'. It may also be helpful to include the reason why the entry wasn't made at the time, eg 'home visit'.
- A computer audit trail will indicate when a patient's records were accessed and changes made, but if there is a significant delay in adding information, it should still be obvious to anyone reviewing the record where and when an entry has been made retrospectively.
- When accessing the patient's records retrospectively, double-check their history in case this would alter any aspects of the advice you have given or the medication you have prescribed. If you discover an allergy or drug interaction, contact the patient concerned immediately to explain what has happened, apologise, and explain what they need to do next.
It's useful to develop an emergency plan that can be employed if an IT system breaks down, covering areas like following up test results, managing patient referrals and repeat prescribing.
Establish a back-up system for repeat prescribing so new prescriptions can be generated and existing prescriptions can be processed.
GPs have additional contractual responsibilities to ensure they use approved computer systems and there are high quality security, audit and system management functions in place. As well as keeping electronic data regularly backed up, it's also worth taking advice from the clinical records software supplier before trying to restore a back-up.
This guidance was correct at publication 31/01/2020. It 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.