Five tips on keeping good medical records

Accurate medical records have always been important but with patients now able to access a summary of their notes, clarity is key explains the MDU's Dr Beverley Ward.

Patients have long been able to access their records under the Data Protection Act 1998. But since March, it has been a contractual requirement that practices must offer and promote to patients the facility to view their coded online records.

With increased access by patients, it’s a good opportunity to review your record keeping policies and protocols to ensure clarity and consistency. Bearing this in mind, here are some tips to for keeping good records:

1. Get the right record

If you are writing your notes by hand in a separate document, for example during a home visit, ensure the note includes enough information about the patient to identify them. This would usually be their name, date of birth, and address.

If your notes are computerised, double check that you are saving them into the correct patient record. It may sound obvious, but the MDU has seen cases where an entry was put into the record of another patient and this was only discovered when the notes were disclosed to the second patient.

2. Write your notes at the same time, or as soon as possible afterwards

This will maximise accuracy, as events will be fresh in your mind, and will reduce the risk of you forgetting to add the note at a later time, such as after a home visit. It will also mean that the records will be in chronological order, making them easier to interpret later. And of course timely record keeping will ensure the key information is there for colleagues who may see the patient again, sometimes shortly afterwards.

3. Protect records from accidental disclosure

You have a statutory duty to store patient records securely and accurately, and to protect them against accidental loss, damage or disclosure.

As well as face to face consultations, the records should include telephone consultations, home visits, discussions with third parties and clinical colleagues, results, correspondence in and out of the practice, and photographs. We advise that complaints correspondence is stored separately from the clinical record, as this is not directly relevant to the clinical care of the patient.

4. Ensure your note is accurate, legible, and contains enough information

A colleague caring for the patient in the future, should be able to pick up from where you left off. As a minimum, your consultation notes should include relevant clinical findings, decisions made and actions agreed, information given to patients, any drugs prescribed or other investigations or treatment.

It should also be clear who has made the note and when. Avoid using abbreviations, as these can be misinterpreted, by your medical colleagues as well as by patients accessing the record at a later date. With written notes, ensure your handwriting is legible,  your name is clear and you note the date and time. With computer records, use your own login so that the audit trail is clear.

Bearing in mind that the notes could be used for other purposes such as court cases, insurance claims, and for employment purposes, be careful how your record information. Make sure you use qualifying phrases such as ‘the patient told me …’,  or ‘the patient said…’ when noting alleged facts, so that no assumption is made about their veracity.

5. Never alter the records

It can be tempting to add information to a note after the event, where you have remembered something significant that you forgot to include at the time. This might happen if you become aware of a complaint and reflect on the events. If you wish to do this, ensure it is clear when you added the additional information and why, so that the timing of entry is clear and your motive will not be misunderstood.

After viewing their records, a patient might ask for information to be deleted or altered. For example, where you recorded a working diagnosis and it later transpired the patient had a different condition. You should listen to the reason for the patient’s request, and explain that you cannot alter a record that is an accurate representation of the situation at the time the note was written, however you can make an additional note recording the patient’s views. 

Only on rare occasions can information be removed, for example when a clinic letter or result has been filed in the wrong patient records. Even then the amendment would need to be clearly marked and dated, and the reason given. It is possible that a decision about the patient’s care may have been taken on the basis of the misfiled result, so enough information should be retained to explain the clinician’s reasoning at the time.

Patients accessing their own records may have questions about their contents, but by taking the time to answer these, you may be able to help them to gain a greater understanding of their conditions and medications.

  • Dr Beverley Ward is medico-legal adviser at the MDU

The MDU offers a seminar to GP Groupcare practices on effective record keeping

Photo: JH Lancy

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