The MDU has developed new guidance for doctors embarking on their first consultant post. In the fourth of a series of articles guiding you through the more common non-clinical challenges you might face, we provide tips on perfecting your record keeping.
Imagine the scenario. A doctor sees a patient who is semi-conscious and decides to give her a penicillin-based antibiotic. They consult the notes which make no mention of any allergy, administer the drug, only for the patient to have a severe allergic reaction and need resuscitation.
The doctor later realises that they had unfortunately been looking at the wrong patient’s notes. The actual notes include details of the patient’s allergy and the hospital doctor realises she is also wearing a wristband warning of her allergy.
This extreme case, though fictionalised, provides a stark example of the value to patient care of effective records. As no one’s memory is wholly reliable, records provide a useful reminder of a course of events, steps taken, outcomes and further action required.
Records are primarily intended to support patient care and should authentically represent each and every consultation (including by telephone). Records can also 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.
The GMC guidance in Good Medical Practice (2006) makes clear that records are a fundamental part of a doctor’s duties. The GMC explains that in providing care, you must keep clear, accurate, legible and contemporaneous patient records which report the relevant clinical findings, the decisions made, the information given to patients and any drugs or other treatment prescribed.
Electronic records
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, in ensuring that information is attributed to the correct patient’s medical records.
Storing records
Records (including hand-written notes, computer-generated notes, blood test results, x-rays, copies of correspondence, photos or slides and theatre records) should be stored securely and protected against accidental loss, including corruption, damage or destruction. 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.
Private patients
As a consultant in independent practice, you may also need to take on the added responsibility of managing your private patient’s medical records. Such records are the property of the individual doctor although patients have rights of access under the Data Protection Act 1998. Make sure that patients know what will happen to the data held about them and that they agree to its processing or disclosure. You will also need to register with the Information Commissioner under the Data Protection Act 1998.
Clinical records must be kept confidential at all times, including during transfer between sites, such as if your secretary works from home and you need to send data to him or her. It is also important to ensure any admin staff are aware of confidentiality obligations, for example, locking paper records away in a suitable filing cabinet and ensuring security of computer systems.
Retaining records
The Private and Voluntary Health Care (England) Regulations 2001, Schedule 3, lays down minimum periods for the retention of private records, ranging from eight years for the majority of records to until the patient reaches 25 years old, for children’s records. The MDU advises that, if possible, records should be kept for beyond the prescribed periods, as claims do sometimes arise after these timescales, and it may prove difficult to successfully defend a claim without the records.
Ideally, all records should be reviewed before they are destroyed, and it is sensible to keep any patient records where there has been an adverse incident or complaint. 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.
Tips for good record keeping
1. Write legibly
Take a little extra time and care to write legibly in paper records. While you may be able to read your own handwriting, can anyone else?
2. Include the date and time
Dated and timed hand-written notes will be invaluable if a claim arises several years later. Such details will clarify the sequence of events during your treatment of the patient, even though you may not be able to remember clearly what happened. With electronic records, the time and date will be automatically recorded.
3. Avoid abbreviations
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.
4. Do not alter an entry or disguise an addition
Clinical notes should be made at the time of treatment or as soon as possible afterwards. If it transpires that the notes are factually incorrect, for example, an entry has been made in the wrong patient’s records, then the amendment must make this clear. 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. Never try to insert new notes. Computer records have an ‘audit trail’ that will allow alterations to be discovered. Tampering with records has led to GMC investigations.
5. Avoid unnecessary comments
Offensive, personal or humorous comments are unprofessional, often misunderstood and could damage your credibility. Patients have a right to access their records and a flippant remark in the notes might be difficult to explain to a judge or GMC fitness to practise panel.
6. Check dictation and reports
Letters dictated and then typed up later by a secretary should be checked, corrected and signed by the doctor who dictated them. Errors can arise due to problems with the quality of recording or simple misunderstandings of medical terminology.
You will need to see, evaluate and initial every report or letter before it is filed in the patient’s records. Most results are electronically transmitted, so care should be taken to record abnormal findings in the clinical records and document any appropriate action.
The MDU’s new consultant pack contains 18 factsheets on subjects such as communicating with patients and colleagues, good record keeping, supervising staff and marketing and media. The pack is available free to the MDU’s consultant members.