Clinical records remind you of what happened during a consultation, actions, steps taken and outcomes. No-one's memory is infallible.
They inform colleagues who may see the patient subsequently, supporting continuity of care.
They provide evidence if the standard of your care is ever questioned.

Recording a consultation

In order to best support patient care, your consultation notes should be made as soon as possible and include the following details:

relevant history and examination findings (both normal and abnormal)
your differential diagnosis and any steps taken to exclude it
decisions made and actions agreed
information given to patients, including the different treatment options and risks explained during the consent discussion
the patient's concerns, preferences and expressed wishes (this will also be valuable if they lose capacity)
drugs or other treatment prescribed and advice given
investigations or referrals made
the date and time of each entry and your identity.

Patient records: what else to include

As well as face-to-face consultations, you should record all interactions with patients and any information relevant to their care, including:

notes of telephone or video conversations and home visits
discussions with clinical colleagues and third parties
test results
photographs and X-rays
correspondence, e.g. referral letters, theatre records (if applicable).

The integrity of records

Make every effort to preserve the integrity of your records so they support patient care and you're not vulnerable to criticism in the event of a complaint or claim. The steps listed below will help you do this.

Complete

As described above, ensure your notes are an accurate reflection of what took place during a consultation and that all relevant information is filled with the patient's record.

Contemporaneous

Write notes as soon as possible while events are still fresh in your mind. Timely record-keeping is important if colleagues need to see the patient again soon afterwards.

Clear and legible

When you need to make a note by hand, take a little extra time and care to write legibly so you and others can read it later.

Entered for the correct patient

Double-check you are entering notes into the correct patient's record.

Don't include ambiguous abbreviations

Some abbreviations for conditions and medication are open to misinterpretation and can confuse other members of the healthcare team. Limit them to those approved in your workplace.

Avoid jokey comments

Offensive, personal or humorous comments could undermine your relationship with the patient if they decide to access their records, and could damage your professional credibility if the records are used in evidence.

Not tampered with

Never try to insert new notes or delete an entry. In written notes, 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. If you remember something significant you can make an additional note, but it should be clear when you added the information and why.

Computerised entries will have an audit trail of all entries and deletions, so if something is deleted there should also be a clear record as to why that was done.

Checked

If notes have been dictated and transcribed by a third party, review them for transcription errors and sign entries before they are added to a patient's records. You should also check, evaluate and initial printed results, reports or letters before they are filed in the patient's records and document any appropriate action.

The HSE has published its own guidance about healthcare records management.

Retaining records

One of the data protection principles is that records should not be kept for longer than necessary. The HSE has published a record retention policy, which includes a detailed schedule for retention periods for different types of health record.

We would advise that these are minimum retention periods, but if you plan to hold clinical records and related data for longer than the HSE policy stipulates you should have a clear purpose and legitimate reason for doing so. It would be prudent to keep any patient records where there has been an adverse incident or complaint, until you know it is concluded.

Destroying records

The above policy also contains advice on the destruction or disposal of records. Ideally, all records should be reviewed before disposal to check there is no need for them to be kept for longer than the minimum period - an ongoing complaint, or the likelihood of a claim, for example.

If records are to be destroyed, then a record of what has been destroyed and when should be retained. The same applies if all or part of the records are sent elsewhere for archiving.

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 you may need to seek appropriate IT advice.

The principles of good record-keeping in the Republic of Ireland

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