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A Guide to Keeping Medical Records

Reliable medical records, whether electronic or handwritten are important for caring for patients in healthcare facilities. Medical records are kept to ensure continuity in follow-up care. Thus, they should genuinely represent all consultations (including those done via the phone). Even if you know your patients very well, memory is not reliable. Records provide an accurate reminder of how events occurred, steps taken, results and additional action needed. Records should be detailed enough that when required a locum physician or any other member of your team can continue caring and treating a patient from where you stopped. Also, the patient records will come in handy in the future when a patient makes a claim or complaint against you. The complaint might be made several months or even years following a consultation. Without adequate medical records, you will not be able to defend your decisions and actions regarding patient treatment in a professional or legal setting. Always remember the saying – poor documentation, poor defense.

When treating and caring for patients, it is important that you keep clear, legible, precise and contemporaneous notes that contain pertinent investigations and clinical findings. The notes should also include the decisions you made, what you told the patients as well as any medications you prescribed.

Electronic Patient Records

These days, the patient consultation records are generally held by electronic means. Taking contemporaneous notes of a patient consultation by means of a computer will ensure that such notes are readable; however such notes should be taken with care. If care is not taken, a particular patient’s information might be attributed to another patient’s records. Also, you should avoid utilizing shorthand in an effort to save time. This is because you might understand what you have written however other doctors who need to use the notes might not.

Storing Patient records

Patient records, which can be computer generated notes, handwritten notes, x-rays, blood test results, theatre records, photos or slides and copies of emails) should be stored in a safe and secure location. Also, such records should be protected against accidental damage, destruction, corruption or loss. Technology can fail sometimes, thus the records should be backed-up on a regular basis.

When doing home visits, you should avoid carrying clinical notes in your vehicle. Ensure that every administrative staff understands their confidentiality obligations. Paper records should be locked up within an appropriate filing cabinet and computer systems should be adequately protected. Taking these measures will help ensure that patient records are kept confidential and secure at all times.

Retaining Patient Records

There is no specific regulation regarding how long patient records can be kept. Medical Council direction regarding patient records retention say that such records should be kept for a sufficient time period. This can be up to twenty one years. You can keep patient records for longer than the recommended period, however common sense should be applied. If, for example, you know that the patient in question has undergone a traumatic experience, or that the patient is still very young, you can keep the record for an extended period of time. When in doubt, it is best to keep the notes.

Before you destroy any record, make sure it has been thoroughly reviewed. Disposal should be done in such a manner that patient’s confidentiality will be protected. For instance, paper records should be shredded. It might be difficult to completely delete electronic records held within a computer hard disk. You should consider seeking assistance from a qualified IT professional for this.

Private patients

There might be need for you to manage the medical records of your private patients. This is more so if you are a specialist in independent practice. The individual physician owns such records; however patients have rights to access the data. Patients should be adequately informed about how their personal data will be utilized and that they do not object to its disclosure or processing.

Tips for Keeping Good Patient Records

1. All records should be written in a readable, clear style

If you make handwritten contemporaneous notes, ensure that they are clear enough for other individuals who require them to read. Even though electronic records are legible and easy to read, you should avoid utilizing text speak or any other form of writing that might not be understood by others who may need to use the records.

2. Do not Make Any Alterations after Making an Entry

Remember that all clinical notes should be taken contemporaneously. This means that the notes should be made during the consultation or soon afterwards. If you discover later that you recorded incorrect information, ensure that the amendment is clear. When you make a mistake, bracket it and then cross it out with a single stroke so that the initial text remains visible. Markers or tipex should never be used. After you have made the correct entry, you should also put the date, time and your signature beside it. For electronic records, you should never try to add or insert new notes. Remember, if you tamper with medical records, it can lead to an investigation by the courts.

3. Abbreviations

It is best to avoid using abbreviations when taking contemporaneous notes. What does tiw mean? Does it mean three times in a week or twice in a week? Instead of writing tiw, write 3 times weekly. If you must make use of abbreviations, then limit them to the ones that are approved within your place of work.

4. Do not include needless comments

It is unprofessional to include humorous, personal, or nasty comments in your contemporaneous notes. Such comments are often misunderstood and might damage your integrity. Remember that every patient have a right to look at his or her medical records. If a patient finds a frivolous comment in his/her record, you might find yourself facing a lawsuit.

5. Check all reports and letters

If you dictate letters to your administrative assistant, then make sure that you check, correct and sign them after such letters have been typed. Errors can arise if a recording is of poor quality or when a medical terminology is misunderstood. Before a report is filed within the patient’s record, be sure to read, assess and sign the report.   These days, the majority of test results are transmitted electronically. Therefore, make sure you record any abnormal findings you find in the test results. Remember to record any appropriate action in your contemporaneous notes.

6. In instances

Where a patient declines treatment, document the patient’s inability to comprehend the consequences of the negative response. If the decision of the patient might hasten death or lead to serious injury, multiple visits might be needed to record the durability of the patient’s decision as well as eliminate other likely reasons for the patient’s decision. While you may at times disagree with the educated choices of experienced adults, you have no option but to respect their choices. Document in such a way that clearly shows that the patient opted to decline treatment by utilizing “consistent with the individual’s informed decision…” Also, you should welcome and record a patient’s constant right to reverse his/her decision and get a recommended treatment.

Thorough documentation is vital, not only for ensuring quality continuity of care and treatment, but to present (in the event there is a lawsuit) the facts upon which you based your decision. As a physician, you can reduce your risk of facing allegations by adhering to proper standards of care, approaching evaluations with an open mind, respecting patient choices and reassessing your view of keeping contemporaneous notes from a necessary evil to an opportunity to provide better quality care to your patients.


Sources

http://www.aafp.org/fpm/2000/0300/p29.html

http://www.hospitaldr.co.uk/blogs/guidance/keeping-medical-records-guidance-for-doctors

http://www.medisec.ie/a-z/medical-records-in-general-practice

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