Medical Notes & Records – Best Practice
Below is the text from an article that Scott Lister and Liz Bardolph prepared for The Expert Witness Journal – Spring 2015
Click here for a copy of the original: Medical Notes and Records – Best Practice
Both Scott and Liz have extensive experience of reviewing medical notes and records for the purposes of investigations and/or litigation. In this article, they provide some advice and ‘top tips’ as to how to keep good medical and nursing records.
It is our experience that healthcare professionals are extremely surprised when there is a complaint or legal proceedings are contemplated/issued by the intense scrutiny that records are under.
Unfortunately doctors and nurses are not given sufficient training about documentation and the expected content and standards, and it is only when things go wrong that health care professionals realise how reliant they are upon their previous notes and records. As can be expected, often these records have been created a long time prior to the complaint or legal proceedings being raised.
The BMA has said “Doctors must keep clear, accurate and contemporaneous patient records which report the relevant clinical findings, the decisions made, the information given to patients and any drugs and other treatment prescribed.”
The NMC’s ‘Guidelines for Records and Record Keeping’ are even more prescriptive when they state:
“… …you have both a professional and legal duty of care. Your record keeping should be able to demonstrate:
full account of your assessment and the care you have planned and provided relevant information about thecondition of the patient or client at any given time and the measures you have taken to respond to their needs.
evidence that you have understood and honoured your duty of care, that you have taken all reasonable stepsto care for the patient or client that any actions or omissions on your part have not compromised their safety inany way.
Record of any arrangements you have made for the continuing care of a patient or client.”
1, Legible and clear
The records need to be legible and clear. Anyone accessing the document/s needs to be able to read and understand the content. If healthcare professionals have particularly bad handwriting then the medical records should be printed so that any one else referring to them can easily decipher them. The records are often the only record of what has happened and accordingly they need to be well written, clear and easy to follow. Bear in mind they may need to be photocopied, so black or blue ink/biro should be used. Hopefully as the National Health Service moves towards an electronic notes keeping system the problem of deciphering colleagues’ hand writing should become less of a problem.
2. Date and time
This may sound like a simple tip but it is absolutely essential that the correct date, time and year be recorded in the medical notes and records. Time after time we see medical notes and records where either the date is incorrectly written or the year is not included. While at the time the note is produced the paper records may flow and it is clear to the reader what has happened, the notes are often found in a disorganised state during an investigation many years later, when it is impossible to accurately work out when the entry was made.
Events should therefore be recorded consecutively.
3. Descriptive text
The medical notes entry needs to be as descriptive as possible. All the information about what has happened and the process that has been gone through needs to be set out clearly. For example, if a patient has deteriorated and new medical interventions have been started, then it seems sensible for the healthcare professional to explain the situation as they found it, the treatments that they considered, and the actual treatment that was instigated. Moreover, it is essential to ensure that when this process is described that any discussions with more senior or allied healthcare professionals are clearly documented. It is important that the process is set out and the reasons for including or excluding the treatment options are documented. Each and every page should contain the patient’s details and be numbered. All entries should be signed and the name of the clinician writing the note should be stamped or printed.
As above it is important that all of the information that has been exchanged during the care afforded to a patient is included within the medical notes. Importantly, it is suggested that if a healthcare professional such as a Junior Doctor calls on the assistance and guidance of a senior member of staff that this is documented within the medical records. For example, in Scott’s practice as a Junior Intensive Care Nurse he would often speak to the Registrar or the Senior Sister who would give advice and guidance on ventilation settings and adjustments to intensive care drugs that were maintaining blood pressure and perfusion. In these kinds of circumstances it is important that the healthcare professional describes these conversations and why any changes to the treatment occurred.
One of the recent interesting developments that we
are seeing more frequently is the use of proforma documents. Although proforma documents are very good and highlight all the information that is required (for example, during a clerking process) it is important that all the relevant information is fitted into the proforma document. The documents are only a guide and are not bespoke to every conceivable clinical situation, and therefore, need to be used with caution. It is also important to ensure that the correct proforma document is being used within the relevant clinical scenario.
A clinician should also make sure that they are using the correct form for the correct purpose e.g. consent and CPR decision documents.
It is important to remember that patients and non- medical people may also be reviewing the medical notes and records. Therefore avoid abbreviations and keep the language simple and straightforward. There are hundreds of abbreviations that can be found and some are local to each hospital or health care practice, again, these are not acceptable and must be avoided.
It is important to keep records contemporaneously. Although it may be quite proper, it can appear odd if a note is recorded sometime after the event without there being a note explaining the delay.
8. Amending records
In a busy clinical environment there will of course be occasions when an entry is made in the medical records that needs to be amended and changed. It is advisable never to remove anything from the records, as this would look suspicious. Merely, cross out the entry, sign, initial and re-write. Never use tippex or similar products.
9. Personal/Judgmental comments
We all know that practising as a Doctor or a Nurse in a busy clinical environment is both stressful and exhausting. Sometimes it is tempting to describe patients’ characteristics in a sarcastic or judgemental manner, particularly when stressed and a patient is thought to have been difficult.
Obviously this should be avoided and all comments should remain professional. In addition one often sees ‘patient reassured’. This is meaningless without a description of what has gone before.
10. Dictated notes and records
It is common to see letters within records that have been dictated but are marked as not being checked.
Secretaries and administrative staff cannot possibly fully understand the dictated note, as they do not have the same degree of medical training as the practitioner preparing the letter. Moreover, there can be equipment failures, which mean it is absolutely essential that the record is checked and signed, and any amendments are made before the record goes out. Both Liz and Scott have dictated many letters and correspondence, which have been typed, but when returned bear little resemblance to the actual words spoken and required significant amendment.
11. Telephone advice.
If advice was given over the telephone, this should be recorded and reasons why a visit was not deemed necessary recorded. This applies to all branches of healthcare, NHS and private.
It goes without saying that all conversations with patients and/or their relatives about their care should be carefully documented as per local protocol and policy. The information exchanged and choices given should be clearly set out along with documentation regarding any printed literature that was supplied. Both Scott and Liz have obtained formal consent from patients for various procedures. Both recommend that in addition to asking for a consent form to be completed that a note is written about the process followed, information given, questions answered and decisions made.
In the event that a patient and or their relative raises concerns about their care then these concerns should be documented and the escalation action taken.
13. Managerial & organisational responsibilities
Senior clinicians and managers also have responsibility to make sure and offer their juniors adequate training and guidance as to best practice and the standards expected. Senior clinicians should regularly review the juniors records to ensure that they are adequate and of a reasonable standard. Moreover, the health care provider/ organisation also has an obligation to make sure it monitors/audits the standard of its documentation, trains, educates, adapts and views the importance of documentation which sufficient reverence.
To conclude, it is absolutely essential to ensure that patients’ medical notes and records are kept in exceptional condition, in a secure environment and all medical information is appropriately recorded and documented. Despite the importance of the medical records they are often not seen as priority. There is no standard model of documentation across the NHS, therefore, it is crucial that practitioners make sure that they are aware of the local guidelines where they are practising. Of course, this is not about preserving health care practitioners’ careers and preventing potential legal issues; it is to ensure that our patients receive exceptional care and those caring for them are aware of the patient’s healthcare journey.
- Guidance for nurses and midwives. 2009/2010.
- B Access to health records. Guidance for health professionals in the United Kingdom. August 2014. Page 2.