A registrar survival guide - Medical records

Medical notes are the most basic tools used in everyday consultations.

Superficially this seems like a straightforward issue. It is drummed into all of us from the beginning of medical school that precise notes are essential. As a GP there are also lots of other things to take into account.

What are medical records?

  • Handwritten and electronic notes of all consultations and correspondence between the GP, patient and other professionals including emails and text messages.
  • Laboratory results and reports.
  • X-rays and imaging reports.
  • Photographs, video and other recordings.
  • Print outs from recording equipment.
  • Consultation notes

Notes should be detailed but not to the point of harming the quality of the consultation. Many patients take umbrage to the doctor fixed on the computer screen. Documentation should include telephone calls, out-of-hours reports and home visits.

Emails and text messaging
Emails and text messaging between the GP and the patient should be used with caution. There should an effective protocol for including this data in the notes. Discussing consultations and medical records over email also has significant confidentiality issues.

Altering notes
Altering notes is, unsurprisingly, not advisable. With clever software being used, easy audit trails are available. You may change the records if the entry is factually incorrect. The original should remain, and a separate entry should be added to correct the mistake.

A patient may ask for some information to be deleted from the record. Notes should only be amended if the original information was inaccurate, misleading or incomplete.

If it is changed, include a note, to say that the incorrect information was altered at the patient's request. If the incorrect information would be harmful to the patient, you can delete it but, again, insert a dated note to explain what has happened and why.

Data Protection Act
As a GP it is essential to understand how the Data Protection Act can affect daily practice. More information can be found on the DoH website.

Essentials checklist
  • An ability to take detailed notes without harming the quality of the consultation.
  • A cautious approach to altering medical notes.
  • An understanding of the Data Protection Act.

  • Contributed by Dr Syed Haque, a GP in East Anglia

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