The Essentials of Record Keeping

Consistent, current and complete documentation in the medical record is an essential component of quality patient care and a fundamental part of a doctor’s duty. Understanding the principles of record keeping will help you comply with your professional responsibilities and protect patients.

Medical records provide a factual reminder of a course of events, steps taken, outcomes, and further actions required. 

Records should ensure continuity of patient care and be sufficiently comprehensive that another doctor can carry on care and treatment where you left off when required.

What’s included in a medical record?

Medical records include not just the clinical entries from a consultation, but all results and medical information relating to the patient, such as emails, consent forms, text messages, verbal correspondence between health professionals, laboratory results, x-rays, photographs, video/audio recordings, and any printouts from monitoring equipment.

Why do we need medical records?

Whilst the main reason for keeping medical records is to aid and enhance clinical care, records are increasingly used for non-clinical reasons such as:

• providing medicolegal evidence
• patient and third-party access to support claims and complaints
• medical audit
• continuing medical education, appraisal and revalidation

Your patient records will be vital in the future if there is a complaint or claim made against you (which will often be made months or even years after a consultation).

In the event of a clinical negligence claim or disciplinary hearing, a doctor’s defence will, to a significant degree, depend on the evidence available in the clinical records. Inadequate medical records may compromise your ability to defend your practice and decisions surrounding patient care in a legal or professional context.

Professional responsibilities

Professional responsibilities for doctors are clearly defined in the General Medical Council, “Good Medical Practice”, which states:

Para 69 “You must make sure that formal records of your work (including patients’ records) are clear, accurate, contemporaneous and legible”.  

Documenting a consultation

Records must be legible, clear and include the author, date and where appropriate, the time of the entry, using the 24-hour clock. Notes should be made following all patient contacts, ie, face-to-face consultations, home visits, telephone advice or video calls.

Your consultation notes should include:

• relevant history, including allergies
• examination findings (normal and abnormal)
• differential diagnosis and steps taken to exclude it
• decisions made and agreed action/management plan
• information given to the patient, including:
  • treatment options and risks explained during the consent process
  • whether a patient leaflet was provided
  • safety netting and follow-up arrangements
• any medications prescribed and discussion with the patient
• any referral made or investigations ordered

Electronic records

Whilst entering notes of a consultation on a computer, it is essential to ensure they are easily understood.

Tips for good record keeping

1. Ensure correct patient identification 
   Patients being ‘mismatched’ to their medical records may cause a serious risk to patient safety. Checking the patient’s identity and demographics will reduce and may eliminate the risk and consequences of misidentification. 
2. Write all records legibly
   Take extra time and care to write notes in a way that is clear to other people who need to read them.
   • The contents of the medical records should have a standardised structure and layout.
   • Documentation within the medical records should reflect the continuum of patient care and should be viewable in chronological order.
   • Data recorded or communicated on admission, handover and discharge should be recorded using a standardised proforma. 
   • Review the patient’s records before seeing the patient, where this is possible.
3. Attribute entries
   Attribution enables correct matching of patient data and communication of information between clinicians. It may also be required for medicolegal purposes.
   • For handwritten records, this should include:
     • date and time (24-hour clock)
     • signature by the person making the entry. Also, their name, designation and GMC number printed against the signature.
     • the new responsible consultant’s name and the date and time of the agreed transfer of care for a handover note.
   • For electronic records:
     • use your unique password to access patient records. Do not share this password with another person. This unique password will attribute entries to the user.
4. Ensure entries are made in the notes following all patient contacts
   Entries should be made following all consultations and whenever any action is carried out on behalf of the patient, ie:
   • face-to-face consultation
   • telephone consultation or advice
   • text and email
   • discussion with another health professional regarding the care of the patient
   • referral to another department
   • if there is a delay, the time and nature of the delay should be recorded
5. Avoid ambiguous abbreviations
   Use abbreviations sparingly and as standardised within your specialty. Shorthand symbols grading clinical findings should also be standardised.
6. Any additions or alterations to existing medical notes should be overt
   Medical records should not be altered or tampered with to obscure the original text. Any changes to documentation should be overt and free from the suggestion that the changes were intended to mislead. Clinical notes should be contemporaneous, made at the time of consultation with the patient, 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 record, the amendment must be clear.
7. Avoid unnecessary comments
   Be aware that your notes may well be seen by the patient, other healthcare professionals and possibly read out at an inquest or in a court of law. The use of offensive, personal or humorous comments is inappropriate and unprofessional.
8. Ensure documentation of any important information
   Certain information that is important to document in the patient records includes:
   • consent for treatment record
   • mental capacity assessment
   • advance decisions
   • lasting power of attorney
   • decisions taken not to attempt resuscitation
   • organ and tissue donation
   • consent relating to children
   • consent to sharing information
   • safeguarding issues
9. Check all letters and reports
   Letters dictated and subsequently produced by secretarial staff should be checked, corrected if necessary, and signed by the doctor who dictated them. Errors often arise due to problems with the quality of the recording or simple misunderstandings of medical terminology. Follow up, evaluate and initial every report or letter before it is filed in the patient’s records.

If you have any queries or concerns surrounding the issues raised in this fact sheet, please do not hesitate to call the PMP medicolegal helpline. The PMP medicolegal helpline is available to customers 24/7. The contact details are in your policy documents, or you can access the helpline through the PMP WebApp.