Good medical records, whether recorded on paper or in electronic format, or a mix of both, are essential for the care of patients.

Medical records are intended to support patient care and should authentically represent each and every consultation (including by telephone or video).

Memory is unreliable regardless how well you know your patients and records provide a factual reminder of a course of events, steps taken, outcomes and further action required.

Records should ensure continuity of patient care and be comprehensive enough that another doctor can carry on the care and treatment of a patient where you left off when required.

Your patient records will be very important in the future if there is a complaint or claim made against you (which will often be made months or years after a consultation). Inadequate medical records may compromise your ability to defend your practice and decisions about patient care in a legal or professional context.

Professional responsibilities for doctors are clearly defined in the Medical Council's Guide to Professional Conduct and Ethics, (available on the Medical Council website) states in section 1.3,

Medical Records

1.3.1 Every physician shall maintain the medical records pertaining to his / her indoor patients for a period of 3 years from the date of commencement of the treatment in a standard proforma laid down by the Medical Council of India and attached as Appendix 3.

1.3.2. If any request is made for medical records either by the patients / authorised attendant or legal authorities involved, the same may be duly acknowledged and documents shall be issued within the period of 72 hours.

1.3.3 A Registered medical practitioner shall maintain a Register of Medical Certificates giving full details of certificates issued. When issuing a medical certificate he / she shall always enter the identification marks of the patient and keep a copy of the certificate. He / She shall not omit to record the signature and/or thumb mark, address and at least one identification mark of the patient on the medical certificates or report. The medical certificate shall be prepared as in Appendix 2.

1.3.4 Efforts shall be made to computerize medical records for quick retrieval.

Electronic Medical Records

Whilst entering the notes of a consultation on a computer, it is important to ensure they are legible and easily understood. Avoid using text speak or shorthand in order to save time as you may understand what you mean but others who need to access the records may not.

Structure of Medical Record

Consider using a constructive method to recording consultations in the record, for example the problem oriented approach S.O.A.P, i.e.:

• Subjective - what the patient tells you i.e. the history
• Objective - what you find on examination and test results
• Assessment - includes problem title and differential diagnosis
• Plan - includes management options

In addition to the above, doctors should include in their records: information given to the patient, safety netting and follow up.

Making Entries into the Medical Records

Entries should be made in the medical record following all consultations and whenever any action is carried out on behalf of the patient, i.e.

• In the consultation room at the surgery
• telephone
• text and e-mail
• administrative tasks
• discussion with another health professional regarding the care of the patient.
• referral to another department
• Entries to the medical record should be made as soon as possible after the event to be documented (e.g. change in clinical state, ward round, investigation)
• Must be made before the relevant staff member goes off duty.
• If there is a delay, the time of the event and the delay should be recorded.
• When there is no entry in the hospital record for more than four (4) days for acute medical care or seven (7) days for long-stay continuing care, the next entry should explain why.

Write all records legibly

Take extra time and care to write notes in a way that they are clear to other people who need to read them.

Dated, timed and signed

Dated, timed and signed handwritten notes are essential not only for continuity of patient care but if a complaint or claim should arise these details will clarify the sequence of events during your treatment of the patient. With electronic records the date and time should be recorded automatically.

Abbreviations and shorthand

Use abbreviations sparingly and as standardised within your practice. Avoid abbreviations which are ambiguous, for example PID can mean - prolapsed intervertebral disc or pelvic inflammatory disease.

Shorthand symbols grading clinical findings should also be standardised. As mentioned above, avoid text speak.

Altering records

Clinical notes should be contemporaneous, made at the time of consultation with the patient or as soon as possible afterward. If it turns out that the notes are factually incorrect, for example an entry has been made in the wrong patient record, then the amendment must be clear. Errors should be bracketed and scored through with a single line only so that the original text is still visible. Do not use tippex or markers if records are handwritten. The corrected entry should be written alongside with the date, time and your signature.

Never attempt to insert new notes. Computer records have an ‘audit trail’ that will allow any alteration to the notes be recorded in real time. Tampering with medical records has in the past led to investigation by the Medical Council and the courts.

Any changes to documentation should be overt and be free from the suggestion that the changes were meant to mislead.

Avoid unnecessary comments

Offensive personal or humorous comments are unprofessional, often misunderstood and could portray a poor impression of you, your hospital or your practice. Patients have a right to access to their records and a flippant remark in the notes is difficult to explain in a court of law or in front of a Medical Council Fitness to Practice committee.

Allergies

To ensure the safe prescribing of medications, it is essential to record allergies in such a way that will alert another healthcare professional to that allergy.

Check all letters and Reports

Letters dictated and then typed up later by administrative staff should be checked, corrected if necessary and signed by the doctor who dictated it. Errors often arise due to problems with the quality of the recording or simple misunderstanding of medical terminology. Follow-up, evaluate and initial every report or letter before it is filed in the patient’s records. Most test results are now electronically transmitted so ensure that any abnormal findings are recorded in the clinical records, as well as any appropriate actions required or taken.

Handover

Handover between clinical teams is considered to be one of the high risk transactions in clinical practice. It is important to ensure that there is documented handover when transferring the care of a patient to another colleague even if on a temporary basis whilst on annual leave.

The Medical Council's Guide to Professional Conduct and Ethics. Edition 8 (2019) states in Chapter 2,

Section 23.1:

“Handover is the transfer of professional responsibility and accountability for some or all aspects of the care of a patient, or group of patients, to another person or professional group on a temporary or permanent basis. You will hand over care when you change shift, refer a patient to secondary care or other health professionals, or when your patient returns to the care of their General Physician. Handovers may take place between teams and/or between individuals.” Many hospitals use an Inter-departmental and shift clinical handover, ISBAR communication tool (Identify, Situation, Background, Assessment, Recommendation, Read-back, Risk), as a structured framework which outlines the information to be transferred. The tool may be available in written format, but preferably electronically.