Patients will soon have the right to access their medical records through the NHS app – which is set to bring a renewed focus on what’s actually contained within a person’s file. If it’s easier than ever for patients to request, inspect and challenge the data kept on them, then the importance of record keeping in healthcare will be thrown into an even sharper focus.
Whether it comes naturally or not, all GPs have to accept that record keeping is a key part of their role. Far from getting in the way of patient time, this part of the job is the thing that informs and guides that patient time. It’s also the thing that protects you and your judgement should this later be questioned.
This post will focus on the importance of record keeping in healthcare and offer a timely refresher of some best practice tips for GPs to ensure they and their patients are on the right track.
Record keeping in healthcare
It pays to remind yourself of the end goal when it comes to your record keeping efforts. This part of the job is all about:
- Keeping detailed information about a patient, their condition and their treatment to ensure you have all of the information you need to hand at every checkup or consultation with them.
- Providing a record that could be picked up by a colleague if they need to pick up the care of the patient for themselves.
- Creating a bank of evidence of the care given to a patient should your actions later be questioned.
Important considerations for good record keeping
The General Medical Council’s ethical guidance outlines how GPs should record their work ‘clearly, accurately and legibly’.
Its advice stresses that any records should be made as soon as possible after the events being recorded and that medical professionals should also be mindful of the laws around data protection so that this information can be safely and securely recorded and stored.
It also states that a patient’s clinical records should include:
- Your name and the date for each new entry
- Any relevant clinical findings you have made
- The decisions you have taken as a result of those findings and any action that you have agree to take as a result.
- An outline of any information you have passed on to your patient
- Details of any drugs prescribed
- Details of any further investigation to be carried out or any treatment required.
This record shouldn’t just be a note of face-to-face appointments, it should also contain important details such as:
- X-rays and scans
- Test results
- Notes from telephone conversations
- Discussions with your colleagues about the patient
- Letters sent or copied in to the patient
- Records of any surgery or hospital visit
Top tips on record keeping
How do you ensure you follow all of the above advice when working on a patient’s medical record?
- Don’t try to alter a file. This is a key point to remember at all times. If you’ve made a mistake then you should correct this with a new entry that clearly outlines what has changed. It’s always best to make a new note, even when you’ve made an error, especially because the GMC frowns upon people who try to delete or change notes.
- Use a good pen if you need to write anything by hand. GP handwriting is notorious – and you don’t want to conform to the stereotype. You don’t need to engage in beautiful calligraphy, but you do need to be understood and a good pen can assist with that.
- Don’t be too personal. These records are professional, factual files and there’s no need to try to write in flowery prose or insert personal comments.
- Check everything. It’s surprisingly easy to log notes against the wrong patient, for example. Check you’ve got the right person – and that all the details you’ve written are correct – before you submit your entry.
If you have any concerns about keeping accurate records, get in touch with MDS to see how we can support you.