Record keeping MPS Guidance for Registrars

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Record keeping (MPS Guidance for Registrars)

• Mufaza Rashid

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Basic principles

• Good records (GMC)
• keep clear, accurate and legible records,
  reporting the relevant clinical findings,
• the decisions made
• the information given to patients,
• and any drugs prescribed
• or other investigation or treatment

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• make records at the same
• time as the events you are
• recording or as soon as possible
• afterwards

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Why

• Complaints and claims
• Audit, clinical governance and QoF purposes
• Missing information wastes time and resources

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Whats included

• Handwritten medical notes
• Computerised records
• Correspondence between health
• professionals
• Laboratory reports
• X-ray films and other imaging
• records
• Photographs
• Videos and other recordings
• Printouts from monitoring
• equipment
• Text messages
• E-mails
• Medical reports, and
• correspondence relating to
• complaints or claims, should be
• filed separately as they are not
• part of the patients medical
• record.

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Computer Records

• Most practices use computer records
• Maybe different but principally the same.
• Important to familiarise yourself with it
• IT training
• Do not share password
• Do not leave unattended when logged in.

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Computer Vs Paper

• A study in the BMJ found that more electronic
  records were fully understandable (89 against
  70 for paper records) and fully legible (100
  against 64)
• They were more likely to include at least one
  diagnosis advice that had been given
• And when a referral had been made, to contain
  details of the specialty.
• Doctors were able to recall more advice given to
  patients (39 against 27).

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• However,
• A study in the British Journal of General
  Practice suggests that a mix of paper and
  computerised records provides the best quality.
• Fewer telephone consultations were recorded in
  paper records.
• Fewer home visits and symptoms in computer
  records.
• The quality of the record of individual
• consultations was highest in
• paper records.

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• More errors are made in computer records due to
  copying text- existing templates or from
  previous notes.
• (American study)

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Emails and text messages

• Need to be recorded onto the records
• Not ideal way of communication due to
  confidentiality issues.

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Tests

• Record any investigations that you order
• It is your responsibility to chase and act on
  them
• So make sure there is a prompt system- find out
  how your practice works

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Altering records

• Do not change the original medical
• record unless the information is
• factually incorrect.
• If you discover an error, insert an additional
  note as a correction.
• Make it clear that this is a new note, not an
  attempt to tamper with the original record.

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Watch out for..

• In a busy practice There will also be
• Home visits
• Out of hours work
• Telephone consultations
• Requests from practice staff to have a quick
  word with a patient

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Tips when starting at a new pratice

• Induction day, which should among other things,
  cover how records are organised.
• Computer records How does the system work?
• Paper records How are records
• filed?
• Abbreviations What abbreviations are acceptable
  and commonly used
• Tests How are they ordered and how is this
  noted in the records?
• Results How do they come back? How will you be
  notified

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Writing good medical records

• Clear, Objective, Firsthand, Tamper-proof and
  original
• Should include
• History
• Examination of the patient
• Diagnosis and detail any further
• investigations
• Information
• Consent
• Treatment
• Follow-up
• Careful with abbreviations- try avoid

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How long should they be kept?

• Maternity records - 25 years after last live
  birth
• Children and young people- 25th birthday or till
  26th if any entry was made at 17. or for 10 yrs
  after death
• Patients receiving treatment for a mental
  disorder- 20 years after the date of the last
  contact or for 10 yrs after death
• All other patients- 10 yrs after death or if the
  pt has permanently left the country (not EU)
• Electronic patient records- not to be destroyed

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Not to be destroyed

• Members of HM Armed Forces Not to be destroyed
• Patients serving a prison sentence

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