Record keeping – how to avoid criticism by a critical eye
Record keeping is a subject widely discussed, the subject of much advice and guidance, but regularly got wrong. It is important that records are accurate, not only to ensure safe and appropriate patient care, but also as a safeguard for you if things go wrong. After all, your records are (or should be!) a first hand, contemporaneous account of your appointment with the patient and therefore, arguably, the most reliable source of evidence as to what happened.
The following 5 points are some suggestions you might want to consider for your records:
- Doctors, like lawyers, are known for their appallingly bad handwriting. Luckily, it is common now for a practitioner to keep electronic typed records using a computer. If you make handwritten records, ensure that they are legible, so that you and others are able to read what you have written (or follow up with a full typed summary/letter). If you’re using computerised records, ensure that there are no typographical errors which may cause your note to hold an entirely different meaning to the note you were intending to make.
- Record your discussions with a patient, the options you have provided them and the risks and benefits of each. Unfortunately, in the increasingly litigious world we find ourselves in, too many times we see allegations being made against a doctor about the failure to inform the patient of all the treatment options, or to warn of possible side-effects or complications.
A patient cannot be expected to remember everything that has been discussed at their appointment with you – with so much information to take in, it is understandable that they may forget parts of the discussion. As well as making a contemporaneous record confirming your discussions with the patient, including treatment options and the risks and benefits for each, it is therefore a good idea to follow that up with a letter to the patient summarising your discussions. That may seem very time consuming, but you may find that you can use precedents or enclose standardised advice leaflets, and use the letter to tailor these to the patient’s own individual circumstances. This will ensure that in the case of dispute, you have a record of what you told your patient.
This will, of course, only be helpful if you have actually discussed and recorded all the relevant options, risks and benefits (including the option of doing nothing). This applies to medical treatment as well as surgical treatment.
- You should always date and sign your notes. Ensuring your notes are contemporaneous is vitally important. The GMC make it clear that your notes should be made at the time of the consultation or as soon as possible thereafter.
You should not disguise any change you make to a record. Sometimes there may be a legitimate reason to go back into the record at a later date and add something to your note, however it is only acceptable to do this if you make it clear that the note you are adding is not contemporaneous and you date and sign the addition or amendment. Seeking to amend your records without making it clear that you are doing so can lead to allegations of dishonesty by the GMC and as you would expect such allegations, if found proven, can result in severe adverse outcomes.
- Avoid offensive language in your notes. The patient can request their medical records at any time. The last thing they will expect to see in their medical records is a flippant remark, or a rude comment about themselves. This could lead to a GMC referral and result in unwelcome publicity about your lack of professionalism which could harm your reputation. Stick to the facts and focus on the treatment.
- Finally, ensure that everything you dictate and any investigations you request are checked by you. Remember, x-rays, test results and correspondence with a patient or their GP form part of the patient’s clinical records. You need to satisfy yourself that a letter being sent out in your name accurately reflects what you have dictated, and that you have reviewed the results of any investigations you have requested. Any errors occurring as a result of you not checking letters or the results of investigations could result in harm to the patient and a claim against you, or a referral to the GMC.
Good records take time and you may feel, quite legitimately, that you simply don’t have time to ensure every detail is recorded. However, if you ever find yourself being hauled before the GMC or on the receiving end of a clinical negligence claim, you will be relieved to have made such comprehensive notes, and I can assure you that you will then save time when meeting with your solicitor to work out what you said to the patient at each appointment, not to mention the fact that you will be better able to defend your actions.
These simple steps could go a long way to covering your “proverbial” if you ever did find yourself before the GMC or at the other end of a claim.