The essentials of record keeping

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, whether recorded on paper, in electronic form or a mix of both, are intended to support patient care. These records reliably represent each and every consultation (including telephone or video). 

Memory is unreliable, regardless of how well you know your patients. However, 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-ray films, 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
  • monitoring performance of hospitals
  • patient and third-party access to support claims and complaints
  • disease prevalence and monitoring
  • 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.

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).

Professional responsibilities

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

Para 19: “Documents you make (including clinical records) to formally record your work must be clear, accurate and legible. You should make records at the same time as the events you are recording or as soon as possible afterwards.”

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.

In accordance with NHS Digital, “Professional Standards for the clinical structure and content of patient records”, 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
  • the date and time, using the 24-hour clock, of each entry and your identity.

Electronic records

Whilst entering notes of a consultation on a computer it is essential to ensure they are easily understood. Avoid using text speak or shorthand to save time; you may know what you mean, but others who need to access the records may not.

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. 
    • Each page of a handwritten record should include the patient’s name, identification number (if applicable) and location, ie, clinic, hospital ward etc.
  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.
  3. Use a standardised structure and layout, in accordance with NHS Digital “Professional Standards for the clinical structure and content of patient records”.  
    • 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.
  4. 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.
  5. 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
    • administrative tasks
    • 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.
  6. Avoid ambiguous abbreviations
    Use abbreviations sparingly and as standardised within your specialty. Avoid ambiguous abbreviations; for example, PID can mean either ‘prolapsed intervertebral disc’ or ‘pelvic inflammatory disease.’ Shorthand symbols grading clinical findings should also be standardised.
  7. 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. Errors should be bracketed and scored through with a single line only so that the original text remains visible. Do not use Tipp-Ex® or markers if records are handwritten. The corrected entry should be written alongside with the date, time and your signature.It is permissible to make additions to the medical record. However, these need to be clearly labelled as such, dated and signed (if paper records).Computer records have an ‘audit trail’ that will allow any alteration to the notes to be recorded in real-time. Tampering with medical records has in the past led to investigations by the GMC and the courts.
  8. 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.
  9. 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.
  10. 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 helpline is open 24/7, and contact details can be found on your policy documents or customer card.

Information correct at time of publication April 2021

Reviewed April 2023

This document does not constitute legal or medical advice and should not be construed as rules or establishing a standard of care. We recommend that you seek independent legal and/or professional advice in relation to your legal or medical obligations or rights. Premium Medical Protection Limited is the owner of this material and its contents are protected by copyright law © 2023. All such rights are reserved.

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