Efficient record keeping is vital to patient safety, quality of care and the demands of clinical governance. Adrian Dagnell, from our medical legal experts Bevan Brittan, gives you advice on how to benefit from good record keeping. Inadequate medical records mean that some litigation claims cannot be properly defended and need to be settled out of court.
Inadequate medical record keeping is a regular part of many fitness to practice cases heard by the GMC, and is often highlighted as a criticism in inquiries and inquests.
Why is it important to keep records?
Some of the main purposes of good record keeping are:
- Patient care: comprehensive, informative health records facilitate continuity and quality of care, and an understanding of the clinical history of a patient
- Complaints, inquiries and litigation: the medical notes are one of the key means by which a healthcare professional is judged. Good notes will protect and assist the medical team, demonstrate appropriate risk assessment and give them credibility in the event of criticism. If there is a dispute about events then courts often adopt the line that ‘If it’s not recorded it didn’t happen!’
- Audit: the clinical and cost effectiveness of care can be assessed by auditing the outcome of the care
- Research national data sets and morbidity registers
Good records can often head off a complaint or claim before it gets started.
- Detailed records confirming the contraindications and risks of a procedure were explained to a patient before it was undertaken can deter a lawyer from taking on a Claimant’s consent-based claim
- Pre-printed information sheets setting out the pros and cons of proposed treatments can be a useful way of providing background information, but they are not a complete substitute for having (and recording) a focused discussion with the patient
- Notes confirming the results of patch tests, energy levels used and the duration of the treatment can prevent IPL claims from being pursued
- Good photographs (pre and post treatment and at reviews) can help to establish how bad (or not!) a patient’s reaction to a treatment has actually been
- Copy records retained by the treating practitioner in addition to the clinic’s notes will help to protect that practitioner if, for example the clinic goes bust and its notes are lost/destroyed
What do good clinical records look like?
- All patient clinical contact and key interactions should be recorded in black permanent ink legibly, simply and accurately
- Every entry should be dated, timed and legibly signed with your name and position. In larger organisations, a stamp can be helpful to ensure that the name and position of the clinician is clearly recorded
- Notes should be informative, complete and up-to-date. Record clinical history, normal and abnormal findings, discussions, investigations, results, drugs prescribed, decisions made, care plan, referrals, special or risk factors. Do not record things that you did not do
- If a mistake is made or notes need to be altered it should be crossed through with a single line. The date and name of the person who has amended the notes should then be recorded. Remember that computer records will have an audit trail that will enable alterations to be identified
- The patient and any other parties at a meeting should be clearly identified with a precise note of the day and time
- Notes should be in chronological order and ideally should be contemporaneous. Contemporaneous notes are given more weight than those made subsequently
- Abbreviations should not be used unless widely accepted
- No jargon, offensive language or gratuitous comments should be made (the records may be scrutinised by a judge in court)
- Records should be stored confidentially. Take care when entering notes on a computer that the information is going on to the correct patient’s medical records. Adhering to these guidelines puts you in a good position to be able to respond to a complaint or claim with hard evidence and maximises the prospects of a successful repudiation, saving you both time and money
If you are a Hamilton Fraser Cosmetic Insurance customer and you are not sure whether an incident should be notified, contact our claims team on: 0345 310 6370.
About the author
Bevan Brittan is a national law firm providing a comprehensive range of legal and advisory services to over 800 businesses as well as being a market-leading firm within health and social care, housing and local and central government.