GPs urged to discuss medical record content with patients

Disputes over medical record content are less likely if GPs discuss with patients what they are to include, according to guidance.

Guidance has suggested discussing medical record content with the patient to reduce disputes
Guidance has suggested discussing medical record content with the patient to reduce disputes

The National Information Governance Board's (NIGB's) guidance suggests that most disagreements over content are caused by GPs' opinions in the medical record.  

It therefore recommends that GPs make it clear in the medical records when opinion is recorded, and suggests it will be less likely that disputes arise if GPs discuss with their patients what they are going to record.

'When we were preparing to produce this guidance, we were made very aware of the stigmas people suffer when inappropriate or provocative comments or opinions are added to their record,' the guidance says.

'We take this very seriously, and we expect that all health and social care professionals will share our concerns and always act appropriately.'

It also suggests good communication with patients on what the information means, why it has been recorded, and how fact may be different from opinion is ‘vital' in settling most concerns.

The NIGB highlights that patients may not know that making changes to an electronic record leaves traces which cannot be completely removed, and therefore suggests GPs may need to explain this to patients if a dispute arises.

Chaand Nagpaul, a GMC negotiator, said: 'There have been considerable advances made in record keeping in recent years with computerised information, but no method is completely failsafe.

'It's in the interests of both doctors as well as patients to ensure records are accurate. So, if there are instances where there is inaccurate information, such as data entered into wrong patient's records, then it's right and proper to have process to follow, which this document provides.'

He added: 'If there is a situation where GPs are recording something of sensitive nature then it is good practice for GPs to discuss the wording of records, but as routine I don't think that it would be practical.'

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