Most non-medical prescribers will normally be alone with the patient during the consultation, whether that takes place in the surgery, home, ambulance or over phone or video call. In face-to-face consultations, your clinical notes may be the only records of the event. In most organisations, telephone calls are recorded and emails can be used to provide hard copy evidence. Skype is also recorded centrally and is backed up in the cloud so this again may be used in evidence. Patients may covertly record consultations and you are advised by many professional bodies that should you become aware of this, you should encourage the patient to be open about this and you can ask for a copy of the recording for your records.
Occasionally, consultations are video recorded when the clinician has a body camcorder or video camera. This could be used and replayed into a court room, either by you in your defence or by the patient to support their grievance, negligence claim or a criminal act. You should be extra cautious with doorbells that have video capability and internal cameras that are linked internally to a WiFi hub. It is often forgotten that not only can someone be watching live from anywhere in the world that has an internet connection, but these smart devices are also capable of recording sound in a high-quality format, which means your conversations are being recorded and can be played back later with sufficient quality to be used in evidence.
At this stage it is worth noting which organisations you will be accountable to, such as the Care Quality Commission (CQC), your professional body (General Medical Council (GMC), Nursing and Midwifery Council (NMC), General Pharmaceutical Council (GPhC) or the Health and Care Professions Council (HCPC), and your employer (Armstrong, 2019a). Therefore, you may have to rely on your record keeping to defend yourself in a civil action for negligence or criminal prosecution (Armstrong, 2019b). Most negligence cases take up to 3 years before being heard in court, by which time your memory of why you prescribed such a medication or the advice you gave will be long forgotten and you will need to rely on the contemptuous notes. Criminal cases tend to be slightly quicker than civil cases, and on average will take 323 days to be heard, but still, you may remember very little of the actual encounter.
In disciplinary or professional hearing, the elapsed time since the event can be shorter still, however the burden of proof is usually lower and you may be defending yourself with only your record to rely on.
What is a medical record?
A medical record is defined by the Information Commissioners Office, in the General Data Protection Regulation (GDPR), that came into force on the 25 May 2018. It superseded existing data protection laws, including the UK Data Protection Acts of 1998 and 2018 (UK Data Protection, 2018). It has been written to reflect the increasingly digital world we operate in and will allow people to take greater control of their own personal data. It states ‘health records include a variety of patient records that are held or filed within a hospital practice, and are not just the main doctor’s record. They include nursing records, health visiting records, X-rays, pathology reports, outpatients’ reports, pharmacy records, etc’ (UK Data Protection, 2018).
With this in mind, it is important that all professional bodies give guidance on record keeping.
The GMC (2013) states it is good medical practice to ‘record your work clearly, accurately and legibly’.
It also states that ‘documents you make (including clinical records) to formally record your work must be clear accurate and legible. You should make records at the same time as the event you are recording or as soon as possible afterwards’.
It states that clinical records should include:
- Relevant clinical findings
- The decision made and actions agreed and who is making the decisions and agreeing the actions
- The information given to the patients
- Any drugs prescribed or other investigations or treatment
- Who is making the record and when (GMC, 2013).
For nursing professionals, the NMC code of conduct (2018) standard on record keeping clearly states ‘keep clear and accurate records relevant to your practice’.
For all other non-medical prescribers, the HCPC notes that ‘once you are registered with us, you have a professional responsibility to keep full, clear and accurate records for everyone you care for, treat or provide other service to the style and structure of your records you keep depend on your profession’ (HCPC, 2018a).
The regulatory authority for the HCPC, as appointed under the Health and Social Care Act (2008) (Regulated Activities), introduced regulations in 2014, called the ‘fundamental standards’. These standards came into force for general practice on 1 April 2015 and replaced, in its entirety, CQC’s Guidance about Compliance Essential standards of quality and safety and its 28 outcomes.
It emphasises the role of record keeping, stating that ‘providers must maintain securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided’ (HCPC, 2018a).
As prescribers, it is also worth noting that guidance from the Royal Pharmaceutical Society’s competency framework for all prescribers should ‘make accurate legible and contemporaneous records and clinical notes of prescribing decisions’ (Royal Pharmaceutical Society, 2016).
The principle of good record-keeping
When conducting good record keeping practice, the following should be observed:
‘Health records include a variety of patient records that are held or filed within a hospital practice, and are not just the main doctor’s record’
Records should be clear and legible. It is important that any handwritten record or prescription is clearly written and is legible. When entering computerised records ensure that entries are for the correct patient and prescriptions are correct, especially when using computer generated prescriptions. Records should be readable when photocopied or scanned. Record should be completed at the time or as soon as possible after the event.
Attribute entries: all records must be signed, timed and dated, if handwritten. If digital, they must be traceable to the person who provided the care that is being documented. Record entries must be attributable to an identified individual and, if using a computer, ensure you have a unique password. Do not let other staff member ‘sign in’ as you.
Don’t use jargon, ambiguous acronyms or abbreviations. Only use well-established abbreviations and avoid those that could be ambiguous. Don’t use jargon, but plain English.
Any alteration to the existing clinical records should be overt. Any additions should be attributable and dated overtly, such as including the reason for the addition such as if the entry was in the wrong patient’s record.
Don’t use offensive, personal, or humorous comments. Using these is inappropriate and unprofessional.
Check everything written in your name. You can be called to account for anything written in your name so ensure that you are aware and have verified anything either handwritten or electronically generated.
Ensure entries are made in the notes following all consultations. This must be done whether the patient contact is at the surgery, home visit, telephone, text or email, when any action is carried out on behalf of the patient such as administrative tasks, telephone calls with another healthcare professional or decisions regarding the patient’s care. When possible, the person in your care should be involved in the record keeping and should be able to understand what the records say.
Prescribers should familiarise and take advantage of consultation templates and prescribing toolkits relevant to their area of practice. Prescribing systems are equipped with templates for consultations related to many conditions, including hypertension, contraception, asthma, diabetes and dermatology. They can provide structure to record keeping during consultations, reminding the prescriber of the relevant information to gather and record. Using a general or condition-specific template can help avoid leaving out critical information from your record, such as examination findings, agreed actions, allergies, information given to the patient, discussion about different treatment options and risks explained, consent obtained, safety netting, treatments prescribed and advice given. For example, if you are seeing a patient for a hormone replacement therapy (HRT) review, the HRT monitoring template will remind the prescriber to check contraindications, blood pressure, body mass index, consider cardiovascular disease risk, risks and benefits of HRT, consider changing or reducing HRT, the relevant advice given, the plan, and follow up. All of the above and more can be documented quickly and accurately.
A general consultation template can help the prescriber record the advice given to patients easily, by pre-populating entries as they are discussed with the patient, making better use of your time during and in-between consultations. The condition-specific templates are comprehensive only for that condition, so best used to support consultations where the agenda of the consultation has been established, ie in a diabetes review.
A general consultation template still encompasses the core elements to support effective record keeping, but is useful where the prescriber is unaware of the reasons for the patient attending, such as in a minor ailments clinic.
If you are not issuing a prescription but the patient is requesting one, such as antibiotics for a viral infection or a medication that is not licensed or permitted by the local authority or hospital, ensure that you record why you are not issuing the prescription and the information given to the patient, such as self-care guidelines, specific safe netting advice given or local authority guidelines. Some computer systems will generate this self-care information and this can be saved to the patient’s record, so you need to make sure you have covered it.
Clinical Entries
The style and structure of the records you keep will depend on your profession. For this reason, more information about this should be available from your professional body and/or employer. As previously stated, it is your professional responsibility to keep full, clear and accurate records, so that you can fulfil the following:
- Share information as required with colleagues
- Ensure service users receive appropriate treatment that is in their best interests
- Meet legal requirements or respond to freedom of information requests or subject access requests
- Evidence your decision-making processes, in case it is later queried or investigated (HCPC, 2018b).
Many professionals use the following structure for their clinical entries:
- Subjective: history of presenting complaint, including patient concerns and expectations as well as past medical history, identifying any risk factors, red flags and discriminators
- Objective: examination, including vital signs and measurements and highlighting the presence of a chaperone
- Assessment: diagnosis and investigations, including proposed management plan, prescription given and details of referrals and future management options
- Information: patient involvement, including information, advice and recommendations that the patient was given and their agreement with the treatment plan
- Safety netting and follow up: details of when the patient should return or seek further medical input. Details of any written information given or advice where to seek further details on their condition, such as NHS website or the patient information leaflet on prescription medication. If self-care information was given and over the counter medication recommendation was provided, this too should be included.
If records fail to have sufficient details, then the practitioner could be liable under a claim for negligence, as in the case of Saunders v Leeds Western HA (1993). In this case, a normally fit 4-year-old girl suffered a cardiac arrest during an arthoplasty operation and, as a result, developed brain damage, quadriplegia and blindness. The theatre staff argued that her pulse stopped abruptly, however, there was no evidence in the records to suggest this was the case. Therefore, as there was no adequate explanation, the court was of the opinion that a normally fit 4-year-old would not normally suffer a cardiac arrest, if the appropriate protocols were used correctly. This case is also an example of Res ipsa loquitur, which allows the plaintiff to infer negligence on the part of the defendant. Res ipsa loquitur is often used in complex cases, where the plaintiff cannot identify the precise nature of the negligence that caused the harm.
This was also endorsed in Marriott v West Midlands HA (1999) where Mr Marriott sustained a head injury that rendered him unconscious. He was taken to hospital but returned home the next day. He continued to complain of headaches, but upon phoning the hospital, his wife received assurances as to his wellbeing. Three days after the accident, Mr Marriott’s own general practitioner examined him, concluding that there were no neurological abnormalities and prescribed painkillers. However, they failed to make detailed notes and were unable to remember any details. Two days later, Mr Marriott was rushed to North Staffordshire Hospital, went into cardiac arrest and had to be operated on. The operation revealed an epidural haematoma and intercranial bleeding, with the result that Mr Marriott was left severely disabled. In an action for negligence brought by Mr Marriott, the High Court Judge awarded damages against both the hospital and the general practitioner.
For this reason, it is important to give details of your assessment and evidence of the arrangements you have made for future and ongoing care, including why you decide to wait and see. In the Marriott case, an incomplete record was fatal to the case. Details of the examination were missing, but equally damning was the lack of evidence as to why the doctor decided to wait and see. Contemporaneous recording is vital as it adds to the reliability of the entry and means that, with the leave of the court, you can refer to the record when giving evidence.
In Kent v Griffiths and Ors (2000), the judge awarded the claimant £36 2377. In this case, a doctor called an ambulance to his patient, who was having an asthma attack. The London Ambulance Service was ordered to pay costs to the claimant, as it was found that there had been contemporaneous altering of a record, which contributed to a finding of negligence. The record prepared by a member of the ambulance crew indicated that the time of arrival at the claimant’s home was 16.47 whereas in reality it was 17.05. The judge considered that he had not been given any satisfactory explanation for the ambulance taking 34 minutes to travel 6.5 miles from its base to the claimant’s home. The judge was satisfied that the crew member had ‘withheld the true reason, whatever it might have been, why it took so long for the ambulance to reach the claimant’s house’ (Kent V Griffiths, 2000). In the absence of any reasonable excuse for the delay, the judge was ‘driven to conclude that the delay was culpable’ (Kent V Griffiths, 2000).
In McLennan v Newcastle (1992), a patient alleged that she had not been told of the relatively high risks in connection to her operation. The surgeon however had written in her notes that the risks were disclosed and understood by the patient, and consequently the judge decided that in all probability the patient had indeed been told of the risks. The written entry was dated at the time of discussion with the patient.
Conclusions
It is essential when prescribing or not prescribing that contemporaneous record keeping is maintained. Good record keeping will ensure that patients have a high standard of care recorded, along with detailed safety netting and the rationale for decisions taken and prescription given. The use of computer generated templates can aid consultation by ensuring that key information is not missed plus recording what information leaflets should be given to patient. At present, it is important to follow COVID-19 legislations on record keeping, ensuring that you add note that the consultation is taking placed during the pandemic.
Key Points
- Full, clear and accurate records should always be kept.
- Records provide evidence of your involvement with a patient.
- Records need to be sufficiently detailed, so they can demonstrate involvement with a patient.
- They should be written at the time or as soon after the encounter as possible.
- Rationale for prescribing or not prescribing medication should be detailed with the necessary information.
- Details of the safety netting advise should given and a follow up noted.
CPD reflective questions
- Is it dated and timed?
- Have I stated why I prescribed?
- Have I stated why I did not prescribe?
- Have I stated when to seek further medical input?
- Have I given a review date?