Medical Records

Good medical records-whether handwritten or electronic are essential for the care of patients in general practice. Medical records are intended to support patient care and should authentically represent each and every consultation (including by telephone). 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 member of your practice or a locum doctor can carry on the care and treatment of a patient where you left off when required. The patient records that you keep 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 will mean you are unable to defend your practice and decisions about patient care in a legal or professional context. Remember the maxim - no notes - no defence.

The Medical Council’s Guide To Ethical Conduct and Behaviour provides that doctors have a duty to maintain accurate and up-to-date records either in a manual or electronic form. The legal requirement for doctors to keep proper records was outlined by the Irish courts1. Maintaining patient’s records is a fundamental part of your duties as a GP and is not an optional extra fitted in where possible. In providing patient care you must keep clear, accurate, legible and contemporaneous patient records which report relevant examinations and clinical findings, the decisions made, the information given to patients and any drugs or other treatments prescribed.

 

Electronic Records

Records of patient consultations within general practice are now usually held electronically. Whilst entering the notes of a consultation on a computer may ensure they are legible it also requires care. 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.

 

Storing and retention of records

According to Medical Council guidance doctors should be aware of your obligations under Data Protection Acts in relation to secure storage and eventual disposal of patient records. All records including handwritten notes, computer generated notes, test results, copies of correspondence etc should be stored securely and protected against accidental loss, including corruption, damage or destruction. Technology unfortunately is not foolproof and regular back-ups should be made. All records should be kept secure and confidential at all times. Avoid carrying clinical records in your car for example if you are doing home visits. All practice administrative staff should be aware of their confidentiality obligations, for example locking paper records away in a suitable filing cabinet and ensuring security of computer systems.

There is no definite guidance on how long patient records should be retained. Medical Council guidance on retention of patient records state that they should be retained for an adequate periods which can be up to 21 years. Use a common sense approach regarding retention of records. For example, if the patient is a child or you are aware that a particular patient has had an adverse incident retain the notes for a prolonged period. “If in any doubt-don’t throw them out”.

 

Tips for good record keeping

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. If you are keeping electronic records these may be legible but avoid using text speak or shorthand that others who need to access the records may not understand.

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 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.

Do not alter an entry or disguise an addition to the 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. 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.

Avoid unnecessary comments

Offensive personal or humorous comments are unprofessional, often misunderstood and could portray a poor impression of you 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 practise panel.

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 GP 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.

Further reading HSE Draft standards and Recommended Practices for Healthcare Record Management September 2012 Department of Health Records Management-NHS Code of Practice (2006).

1Toal v Duignan (1991) ILRM 35

View Kate McMahon Newsletter Article winter 2016.

 

Retention and Access to Medical Records FAQ

Is a Patient entitled to their Medical Records?

A patient is entitled to a copy of his/her records (provided it does not put their health or the health of others at risk, or reveal information about third parties without their consent).

Should consultant letters or notes be included when sending a patient a copy of their file?

Out of courtesy consultants could be notified of the intent to release a copy of the notes within a specified time frame should a GP choose to do so. However, the patient is entitled in the ordinary way to a copy of the entire content of their records including letters and reports from consultants without their consent being necessary, and in accordance with the provisions of the Data Protection Act. A consultant’s consent would be necessary prior to the disclosure of records that contained an expression of his/her opinion regarding the patient which was given in confidence or on the understanding that it could be treated as confidential. In appropriate cases (psychiatric illnesses for example) actual views of the consultants should to be sought should the GP be unsure as to whether releasing such records could pose a significant threat to a patient’s health.

What arrangements should be in place for the records of a deceased GP.

Overall where a doctor dies, the best arrangement is for all records to be taken over by a colleague within the practice or a Practitioner in the area who takes over the Practice or the GMS List from the date of the Doctor’s death. If this is not practical, particular records can be returned to individual patients for transmission to their new General Practitioner. Whoever takes charge of releasing records to patients should take a record of all files sent out and should also hand out the files to patients in sealed envelopes for confidentiality reasons. The patients should then be encouraged to pass the files on to their new GP.

The arrangements in all cases should be in consultation with the Executor of the Doctor concerned.

Who is entitled to records of patient to be made ward of court?

The party entitled to a copy of the records is the party who holds the Power of Attorney – assuming a Power of Attorney exits. Otherwise the next of kin applying to become “Committee”* in the High Court Application will usually be provided with copy records if required.

*“Committee” is a reference to the person appointed by the Court to act on behalf of someone who is made a Ward of Court.

If I receive a Solicitor’s letter requesting medical information on a psychiatric patient of mine who had allegedly assaulted his client should information be given?

You should not provide such records to the solicitor representing a victim in the absence of the patient’s written informed consent. Having regard to the patient’s illness there may be problems in such a patient providing consent. The solicitor should only be provided with such records on production of the patient’s written informed consent or an Order of the Court.

How long should I keep patient’s records?

There is no national guideline on the length of time patient records should be retained. Medical Council guidance indicates that in some circumstances records, particularly those relating to pregnancy or children should be kept for 21 years or more. In practice a common sense approach should be taken. If you know the patient has suffered an adverse event retain the records as these will assist greatly if there is a complaint or a claim. You can, if required transfer clinical records to the National Archives for storage rather than destroying them.  See guidance under Retention of Medical Records.

One of my patient’s had genetic testing recently and does not want his family to know the results. What should I do?

The Medical Council states that anyone who wishes to have genetic testing must be counselled beforehand about the possible consequences of testing not only on them, but on their relatives. Always try to obtain the patient’s consent in these circumstances but if consent is refused disclosure may be permitted in the public interest.

One of my patients died recently and his son wants some details regarding his father’s medical records. Can I give him the information?

According to the Medical Council guidance your duty of confidentiality continues after a patient has died. This is an ethical requirement and not a legal one as the right to sue for a breach of confidentiality dies with the patient. If your patient has requested that any information remain confidential you should respect his wishes. If the deceased patient has not given you any instructions regarding his personal information take into account why the information is required and whether or not the information would be of benefit or detrimental to the family.  See guidance under request for a deceased patient’s medical records.

Is consent required from a patient for release of medical record to his/her employer?

The question of a patient’s consent in relation to release of report to an employer should be viewed with caution. For standard reports i.e. referring to patient being absent due to influenza would be in the ordinary way covered by the initial consent.

A GP does some occupational Health work for a company. One of the employees is taking an action against the company. The company is requesting a Medical Report on the patient. The patient originally signed consent with the company for GP services. The patient is now not willing to give consent to release report. Does the original consent signed by the patient imply consent in the circumstances?

Bearing in mind that litigation may be imminent against the employer, it would appear that the original consent signed by the patient would not apply in this case and further patient consent should be sought.
NB – if litigation is imminent – seek supplementary written consent from the patient.

Is the patient entitled to a copy of the report?

The patient cannot be furnished with a copy of the report without the consent of the company – although the company can be asked for such consent and approval. Normally a company would be unlikely to withhold consent.

One of my patients has been diagnosed with a sexually transmitted disease. Can I disclose this information without his consent?

Doctors are required to disclose otherwise confidential information to public health authorities under the Infectious Diseases Regulations. Notification of certain infectious diseases is required by law and does not contravene data protection legislation.

I have often been asked for medical reports regarding patients from employers or insurance companies. Some patient’s do not want me to disclose particular details of their history. What should I do?

Before disclosing any personal information to an employer or insurance company you must have the express consent of the patient. Any requests from employers or insurance companies should be discussed in detail with the patient and the patient made aware that this personal information may be shared with non-medical personnel. In certain circumstances you may ask the employer or insurance company to amend their requests for information so that relevant information only is supplied and not sensitive personal information.

 


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