Definitions
The Data Protection Act 19981 defines a health record as:
‘any information relating to the physical or mental health or condition of an individual that has been made by or on the behalf of a health professional in connection with the care of that individual. This includes a variety of materials including case report forms, printouts from electronic measuring devices, photographs and computerised records.’2,3
In the year 2004–05, the ambulance services in England alone received more than 5.6 million emergency calls and undertook more than 12.8 million planned patient journeys4 this resulting in a vast quantity of healthcare records.
Whilst there are a variety of forms that health records can take, the focus of this chapter will be upon note taking and manual/electronic patient case notes. It is important to note that each individual workplace will have a differing set of documentation requirements however adherence to these general principles is widely accepted.
Why keep healthcare records?
There is considered opinion that good record keeping is a mark of a skilled and safe practitioner.2,3,5 However, beyond this opinion there are many functions served by healthcare records and these reasons can be split into primary and secondary functions (see Box 9.1).
The primary purpose of healthcare records is to support quality patient care and maximise safety for all parties.6,9 The ability to utilise documentation as an aide memoire can assist in the provision of timely and effective patient care. Within a multidisciplinary healthcare system the ability to communicate is key, with both written and verbal communications commonplace. To ensure this continuity and quality of care, professional standards and expectations are set by the registering bodies of all healthcare professions.5,7,8 Records are a valuable resource because of the information they can and should contain. High-quality information underpins the delivery of high-quality evidence based healthcare and other key service deliverables. Information has most value when it is accurate, up to date and accessible when it is needed.8,11
A secondary function of health records as a medico-legal document is a core function in an ever-increasing litigation aware society. With increased public awareness of litigation and complaints policies, accurate and comprehensive records are essential in safeguarding the healthcare practitioner.10 This is perhaps best emphasised by the Nursing and Midwifery Council (2002)5 who state that, ‘If it is not recorded, it has not been done’. The value of high quality accurate records is key in any complaint or claim that may arise; as such resources are a key piece of evidence.12
- Aide memoire
- Communication
Source of information for:
- Clinical audit and research
- Resource allocation
- Epidemiology
- Service planning
- Performance monitoring
- Evidence based clinical care
- To meet legal requirements, including requests from patients under subject access provisions of the Data Protection Act or the Freedom of Information Act
As well as enabling high quality care for patients, good medical and health records are of value in improving standards of care. The continued audit of records plays an important part of the clinical governance process. Clinical governance was introduced in 1998, at the centre of the NHS drive to create a modern, patient-led health service, with the fundamental aim being the provision of responsive, consistent, high-quality and safe patient care. Clinical governance was born out of the need for accountability for the safe delivery of health services. This was due partly to the public’s and professionals’ perception of systemic failings within the NHS. Clinical governance was defined in the 1998 consultation document ‘A First Class Service: Quality in the New NHS’ (p.33)13 as ‘A framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish’. Through high quality documentation and record keeping the health service is able to monitor a variety of areas such as epidemiology of disease and the effectiveness of current treatments. Within this culture high quality care is proposed to flourish.
What constitutes good medical records?
Whilst the need to keep accurate patient, client and user records is recognised by the bodies that govern healthcare practice including the Health Professions Council (HPC),7 General Medical Council (GMC)8 and the Nursing and Midwifery Council (NMC),5 there is currently very little evidence to support a specific standard of record keeping. Current guidelines are based upon expert opinion of what should constitute good medical records and documentation.
Recommendations
- Records should be clear, accurate and legible, reporting the relevant clinical findings, the decisions made, the information given to patients, and any drugs prescribed or other investigation or treatment.8
- Record any important negative findings that occur. For example the absence of a non-blanching rash in a sick child.2,3
- Records should be made at the same time as the events you are recording or as soon as possible afterwards.8
- You must keep notes for any patient that is treated or who asks you for professional advice or services.7
- Any records should be objective – opinions should be based upon facts that you have recorded not speculation. Remember the patient has a right to view their records, therefore any unjustified statements may be disputed.2,3
- First hand – if the information has been passed to you by anyone other than the patient, record that person’s name and position.2,3 For example are they a friend or a relative?
- Records should be tamper proof – any attempt to amend records should be apparent. For example write in pen, not pencil.
- Records should be the original documentation; any alterations should be dated, timed and signed. This is to make it clear that it is not an attempt to tamper with the document but to make a correction or addition.2,3,7
- If you make a correction to any health record the data should not be erased or made difficult to read; instead it should be made clear that it has been superseded.7 For example place a single line through it. Again any change must be signed, timed and dated.
- Involve the client and/or carers in the documentation process.18
- Ensure that records are kept confidential and secure.18
- Only use accepted terminology in health records.19
Models of record keeping
Whilst there is no evidence to support a single method of documenting clinical findings the principle of a consistent, organised and structured approach is vital. Below you will find a suggested model for the free text documentation of any patient (Box 9.2); this is by no means the only model available and each individual practitioner should consider what model is best suited to their own and organisational needs. The described format provides basis for documenting any clinical episode.
Whilst this model encourages a thorough and comprehensive examination, it may not always be the most suited to a critically ill patient, therefore it can be modified with irrelevant sections being minimised. The use of a single structure will allow for continued standards of documentation to be adhered to.
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