Good record keeping
Senior Clinical Teaching Fellow, Institute of Clinical Leadership, Warwick University
E-mail: veronicawilkie{at}doctors.org.uk
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Abstract |
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 TOP Abstract The GP curriculum and...A brief historyWhy is it important...What sort of information...What if the person...What sort of consultations...The pros and cons...How long do records...What safeguards should be...Who can access the...Can patients ask for...Who else can access...ConclusionReferences |
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Keeping good notes is essential for effective medical care and for the day-to-day smooth and safe running of general practice. The GMC states as part of Good Medical Practice that:
In providing care (a doctor) must:
- Keep clear, accurate and legible records, reporting relevant clinical findings, the decisions made, the information given to patients and any drugs prescribed or other investigation or treatment
- Make records at the same time as the events you are recording or as soon as possible afterwards
However, it is worth taking a step back and thinking about why good medical records are essential and how best to keep them.
The GP curriculum also recognizes the need for good records in the Curriculum statement 2 (The General Practice Consultation) advising that GPs should be able to show that they are capable of:
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A brief history |
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TOPAbstractThe GP curriculum and...A brief historyWhy is it important...What sort of information...What if the person...What sort of consultations...The pros and cons...How long do records...What safeguards should be...Who can access the...Can patients ask for...Who else can access...ConclusionReferences |
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Medical records in primary care illustrate how record keeping has changed. Before the start of the NHS, A5 ‘Lloyd George’ envelopes were introduced (named after the politician who oversaw the project). These were designed to hold essential medical records and followed the patient as they moved and changed GP surgeries. If you were to look at entries in the 1950s, they were brief, for example,
- 9 10 52 Tonsillitis Penicillin
- 7 8 50 Psychotic admit
Throughout the 1980s coinciding with, but not necessarily because of, the introduction of vocational training, medical notes started to get longer, with more information on the symptoms of the condition. They would more often include relevant negatives and positives as well as details about treatment and follow-up which the patient required.
Some doctors used a mnemonic (SOAP) described by Lawrence Weed as part of his description of Problem Orientated Medical Records [originally developed for hospital records, for an early electronic database (Savage)]
- S—Subjective; the history
- O—Objective; the examination and any test results
- A—Assessment; the explanation of the identified problem, with each active problem concluding with
- P—Management Plan of investigations (Dx), treatment (Rx) and education (E)
Throughout the 1990s, the increasing volume of patient records, partly due to rising information flow to and from secondary care and increasing use by other team members, led to the increasing use of A4 folders instead of the traditional A5 ‘brown folders’. The use of electronic records became increasingly prevalent with some practices bypassing the use of A4 folders. As the 1990s progressed to the new century, more and more practices were becoming paper light, entering all of their data directly onto the computer, and storing pathology results, and clinical letters on the system. The move away from paper records was further accelerated when the audit requirements of the new GP contract ‘nGMS’ made it nearly impossible to use anything other than electronic records. Both paper and computer records have evolved with the sophistication of health care to provide the right information to the right person to enable the safest patient care. For the remainder of the article, I will assume that the records are electronic, although the main principles also apply to any paper records. Some doctors, especially in secondary care and the US, may dictate notes which are then typed onto paper or electronic records.
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Why is it important to keep good notes? |
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TOPAbstractThe GP curriculum and...A brief historyWhy is it important...What sort of information...What if the person...What sort of consultations...The pros and cons...How long do records...What safeguards should be...Who can access the...Can patients ask for...Who else can access...ConclusionReferences |
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There are several reasons
The patient
Good records are key to patient safety. In general practice, the notes follow the patient as they move and with this moves their past medical history and hospital letters. Hospital notes do not move with the patient but are kept in the hospital; general practice records therefore are currently the only summary of care a patient may have received as he or she moves around the UK. As a patient moves, the paper records (and currently a paper printout of the electronic practice records) are recalled by the Primary Care Trust (PCT). This process can take many months before these paper records arrive at the patient's next practice (during which time the patient demographics and screening needs will have been entered into the PCT database). It is possible to ‘expedite’ notes for those patients whose clinical condition requires the notes to be accessed urgently. These notes can then be made available in a few days.
Good record keeping means that other doctors and members of the health-care team can pick up the patient's story, and increasingly these records can be shared with the patient and accessed electronically in a few pilot sites around the UK. Records are primarily there to support patient care and any consultation, whether in surgery, on the telephone or home visit must be recorded.
There is increasing use of patient held electronic records, with a variety of pilot projects also looking at remote access by patients to their records and improving the interface between primary and secondary care. Patients have carried their own antenatal notes for years.
The doctor
Well-organized records means that a doctor can pick up the patient's story either at the same time as seeing the patient or as part of a review of past history when necessary. Poor notes that are poorly organized or handwriting that is barely legible can make it difficult to pick up the clinical story from previous consultations or problems. Well-kept records can be used to provide reminders and actions for the next visit, advising what the patient has been told or what letters or pathology results should be expected. The doctor will be able to see how many times the patient has been seen or visited which can also trigger an understanding of the severity of the condition. Well-kept electronic notes will summarize current prescribed medications and when routine reviews are due.
Other members of the team
Most practices include the practice nurses who are able to input and access medical notes but also other community staff who are directly involved with the patient (such as district nurses, health visitors and community midwives); this also provides a wider picture of the clinical activity. Some PCTs use anonymized entry frequency from the practice electronic record to audit community nurse activity.
The practice administration team
All documents relating to a patient can be held in one folder (if paper) or file (if electronic), which means that reports and documents can be retrieved; many practices use integrated electronic systems to look at call and recall systems as well as quality audits and clinical governance.
Training and Continuing Professional Development
Reviewing good clear notes with a trainer or once qualified as a GP, discussing notes with a mentor is a valuable way of discussing patient cases and problems and where appropriate reviewing performance.
Critical event analysis
Review of records can help with critical or significant event review or to look at how certain patients were cared for in order to understand and promote good practice.
The NHS
Current quality data is retrieved anonymously from the practice to look at performance against set standards and currently to provide payments against this.
The law
The Medical Defence Union and the Medical Protection Society are very clear that good records kept contemporaneously can prevent unnecessary legal action against a doctor and that good records are essential if patient complaints are to be handled appropriately.
Other agencies
With the patient's consent, medical records can be used to fill in forms for insurance claims, benefits or background information to allow risk assessment for mortgages, life assurance, etc.
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What sort of information should be recorded? |
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TOPAbstractThe GP curriculum and...A brief historyWhy is it important...What sort of information...What if the person...What sort of consultations...The pros and cons...How long do records...What safeguards should be...Who can access the...Can patients ask for...Who else can access...ConclusionReferences |
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Any information needs to be ‘clear, legible and use as few abbreviations as possible’.
When thinking about recording information, it is as well to think about what sort of information you would like if you were the next doctor seeing that patient. It is vital to know the basics, name, age or date of birth and sex; these are often immediately apparent on an electronic record. This can help recognize a potential patient in the waiting room even if they cannot hear their name being called. Past medical history alerts us to vital co-morbidity. Recent consultations may give an indication of what the patient has come for, how often they have been seen and by whom. Good records make it easy for the notes to be scanned through before calling the patient.
Your notes should reflect what has gone on in the consultation and at the least:
- The history, the patient's story and social and occupational history
- Relevant medication or past medical history
- Description of the examination with relevant positive or negative findings
- Your conclusion, diagnosis and management plan
- What the patient has been told, any discussion and follow-up plans
Computer records can organize the information so that when reviewing a certain condition, all entries relating to that condition are revealed in date order. It is possible to see, for instance, that the patient had not attended for a review of his diabetes for over a year. All this adds to the patient's story before you have even started to write your own notes.
When writing your own notes, therefore, the computer will prompt a similar structure to that proposed by Lawrence Weed. It might look like:
- Problem; Hypertension
- History; Started on some new medication (felodipine) 2 weeks ago and has noticed his ankles are swelling, has not been short of breath and has otherwise felt well
- Examination; BP 142/80, slight ankle swelling ...
The computer might also allow us to record family history, social history, look at medication and adherence with its use as well as any referrals or laboratory investigations. The art is putting enough down so that all relevant negatives and positives are represented as well as enough of the patient's history without writing so much that it takes 30 minutes per patient and the amount is so long that subsequent doctors miss information when quickly reading through.
Computers code conditions as initially ‘Read’ codes (developed by Dr James Read and then purchased by the NHS in 1990). The coding term now used is an evolution of Read codes and a system developed by the College of American Pathologists ‘SNOMED’ (Benson). Each clinical condition has a code that links it to similar conditions and allows the computer to recognize that condition and if asked identify other similar conditions. Mistakes used to happen when a GP had bad handwriting; the computer equivalent is putting in the wrong code, so that the diagnosis is then confused or the patient is not recalled.
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What if the person you are seeing is not registered with the practice? |
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TOPAbstractThe GP curriculum and...A brief historyWhy is it important...What sort of information...What if the person...What sort of consultations...The pros and cons...How long do records...What safeguards should be...Who can access the...Can patients ask for...Who else can access...ConclusionReferences |
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Paper records:
- Portable
- Require no typing skills, but need to be written so that the notes are legible
- Can be related to clinical incidents for patients who are not registered as well as those who are registered
- The doctor can draw diagrams
- Records are available in power cuts and require tidying but no upgrading or server backups
- The original letters can be stored
- Paper files can be lost or misfiled
Electronic records:
- Not portable unless hand-held ‘palm’ devices are used; these need to have information uploaded and downloaded
- Users need to be trained to use them
- Users need to be able to type
- Can be accessed across a wider system (i.e. patients records can be accessed in more than one room/computer at the same time)
- Can integrate appointments, clinical letters and referrals
- Can provide graded access to members of the team to provide more privacy
- Can be used for administrative tasks where needed
- Audits easier to do
- Networks may make privacy harder to ascertain
- Medication easier to manage
- Will be better able to network with, for example, community pharmacies and hospitals in the future
- All documents can be electronically transferred or scanned in
- Any changes are tracked and can be viewed
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What sort of consultations should be recorded? |
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TOPAbstractThe GP curriculum and...A brief historyWhy is it important...What sort of information...What if the person...What sort of consultations...The pros and cons...How long do records...What safeguards should be...Who can access the...Can patients ask for...Who else can access...ConclusionReferences |
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Any contact with the patient or about the patient and their care (e.g. telephone calls from relatives, community or hospital staff) should be recorded. Any system should allow telephone calls and emails to be stored and recorded as well as consultations in the surgery or during home visits. Many computer systems have palm-held devices allowing clinical staff to download electronic notes and upload consultations as they happen. Where this backup is not available, the clinician should record the consultation as soon as practically possible.
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The pros and cons of electronic and paper records |
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TOPAbstractThe GP curriculum and...A brief historyWhy is it important...What sort of information...What if the person...What sort of consultations...The pros and cons...How long do records...What safeguards should be...Who can access the...Can patients ask for...Who else can access...ConclusionReferences |
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A record should still be kept. The NHS has a temporary patient form, which can be written on and is then sent back to the patient's own practice. GPs now see patients who are referred by other GPs (as practitioners with a special interest); the records need to follow the same governance as with those patients who are registered. The practice may have a system of recording the information on the computer system, as ‘unregistered patients’ or may have separate paper notes (that need to be stored in a secure place).
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How long do records need to be kept? |
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TOPAbstractThe GP curriculum and...A brief historyWhy is it important...What sort of information...What if the person...What sort of consultations...The pros and cons...How long do records...What safeguards should be...Who can access the...Can patients ask for...Who else can access...ConclusionReferences |
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Current guidance on NHS records is that records need to be kept for 8–25 years (maternity records 25 years, those with mental health problems for 20 years). Those of prisoners and from the armed forces are never to be destroyed. Current advice is that General Practice records are kept for 10 years after the conclusion of treatment and general hospital records for 8 years .The Defence Unions advise that the longer a person's records are kept, the better.
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What safeguards should be in place when a practice moves from paper to electronic records? |
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TOPAbstractThe GP curriculum and...A brief historyWhy is it important...What sort of information...What if the person...What sort of consultations...The pros and cons...How long do records...What safeguards should be...Who can access the...Can patients ask for...Who else can access...ConclusionReferences |
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GPs have to apply to the Primary Care organization who will scrutinize that among many other things:
- the computer system is fit for purpose
- there are good security measures in place
- the practice is following good codes of practice (guidance is available from www.dh.gov.uk/confidentiality)
- there is a recovery plan in case of disaster (What will the practice do in a power cut, where are the back up tapes stored and is there a fire safe?)
- the practice is registered under the data Protection Act 1998
The practice also needs to ensure that all its staff are trained, so that confidentiality is maintained, and that clinicians know how to enter data correctly. A GP study in 2003 showed that computer systems were not as complete as paper, fewer home visits were recorded and fewer symptoms, possibly reflecting that the doctors in the study found it easier to use paper than a keyboard (Benson, 2002). So any practice needs to ensure that computer use does not reduce recording of activity and that confidentiality is maintained at all times.
Data on computer systems is encrypted on the hard disk and should only be accessible by a secure password. Practices need to make sure that computer screens are not visible to any unauthorized people. Paper records can be shredded once a document has been scanned and is in a secure format, with appropriate safeguards in place.
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Who can access the records and who can be sent information? |
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TOPAbstractThe GP curriculum and...A brief historyWhy is it important...What sort of information...What if the person...What sort of consultations...The pros and cons...How long do records...What safeguards should be...Who can access the...Can patients ask for...Who else can access...ConclusionReferences |
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This article will only provide a very brief summary as confidentiality is a large subject which requires more space than this article can provide. In brief:
The information in the notes is only for the use of the clinician who is directly involved in the care of the patient. Guidance on whether information can be shared was made in the ‘Caldicott Report’. The Caldicott Committee, chaired by Dame Fiona Caldicott, aimed to ensure that patient-identifiable information was only shared for justifiable purposes. All flow of information had to be justified against the following principles:
- The purpose can be justified
- Information should only be sent when absolutely necessary
- Only the minimum that is required
- Access to all patient-identifiable information should be on a need to know basis only
- Everyone must understand their responsibilities
- Each transaction must comply with the law
Each health-care organization should have a Caldicott Guardian, this could be a senior member of the management team, senior health-care or social care professional or the lead for clinical governance. The guidance states that individual general practices do not need to have a named Caldicott Guardian, but do need to have an Information Governance lead who is supported by a clinician. It is clear that the future of electronic health records will mean that these guardians and leads for information governance will have to become increasingly vigilant as the national program for IT progresses.
Patients are entitled to access their records, and this access is governed by the Data Protection Act 1998. The act gives every living person, or their authorized representative, the right to apply for access to their health records and to obtain copies. If you are approached by a patient for access you need to:
- Ensure you know that the identity is correct or that there is consent if not the patient (you should write to the patient with a consent form to be signed)
- The request should be logged and complied within 21 days (unless exceptional when delays of greater than 40 days should be explained in writing)
- A health professional can check the records and can limit or deny access if the information could cause serious harm to the physical or mental health of the patient or any other person or the information contains information about a third party who has not given consent
- The patient can be asked to pay a fee and a date set for them to review the notes (or part of) or be given copies
- If the patient is unhappy, they can be directed to the information controller for arbitration
Very often, a practice will opt to allow the patient time to discuss the records with a doctor.
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Can patients ask for something to be removed from their records? |
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TOPAbstractThe GP curriculum and...A brief historyWhy is it important...What sort of information...What if the person...What sort of consultations...The pros and cons...How long do records...What safeguards should be...Who can access the...Can patients ask for...Who else can access...ConclusionReferences |
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The defence unions advise that nothing is removed from the records but that patients can be allowed to file a comment saying why they disagree with a particular entry or why they have asked it to be removed. In the case of a misfiled entry or an entry in the wrong notes, the patient's comments would flag this up. In the case of an entry that was made many years ago or by a different doctor, it allows the patients’ view to be recorded, without interfering with the recorded consultation made at the time.
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Who else can access records? |
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TOPAbstractThe GP curriculum and...A brief historyWhy is it important...What sort of information...What if the person...What sort of consultations...The pros and cons...How long do records...What safeguards should be...Who can access the...Can patients ask for...Who else can access...ConclusionReferences |
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Very rarely information can be made available in the ‘public interest’ which is usually for a severe crime such as murder. If you are not convinced, there is enough grounds for disclosure; the police would need to seek an order from a judge under the Police and Criminal Evidence Act 1984 (schedule 1) for the information to be disclosed. Other public interest disclosures might include where harm or abuse is suspected. When a doctor does disclose this information, a clear record should be kept with the reasons for so doing described.
Parents of children are entitled to see the children's records unless the child is over 16 or the child is under 16 and is ‘competent’ or mature enough to understand what is involved. If parents are divorced both parents have equal rights unless these have been removed by a court. In disclosing to parents, the best interests of the child are paramount (i.e. a doctor may still withhold if he/she believe the child's best interests were not being upheld). It is good practice to tell the child and discuss why information is being disclosed if appropriate.
Representatives of patients who do not have the capacity may ask to have access to records. If the doctor is happy that the person is not able to consent and that disclosure of information is in the best interests of the person. (The doctor should have made good attempts to discuss this with the patient in a situation or time when their capacity to understand is at its best.) Again the doctor should record his findings and decision and why a disclosure was made.
Relatives will sometimes ask if they can have a copy or see the notes on a patient who has died. The legal position is that the ‘duty of confidentiality remains after death’, and any wishes a patient had made explicit before death should be respected. Medical information can be disclosed with the authority of the ‘personal representative’ of the dead person's estate or if a claim is being considered, the access is allowed under the Access to Medical Records Act 1990. As with access when the patient is alive, a Doctor may deny access if disclosure would cause serious harm to the physical or mental health of an individual.
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Conclusion |
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TOPAbstractThe GP curriculum and...A brief historyWhy is it important...What sort of information...What if the person...What sort of consultations...The pros and cons...How long do records...What safeguards should be...Who can access the...Can patients ask for...Who else can access...ConclusionReferences |
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Good record keeping, done in a way that is clear, legible, well laid out with relevant information, is essential for patient safety and permits the smooth running of general practice. Every doctor needs to ensure that all patient contacts are recorded and to respect the right for confidentiality, ensuring that any records system, whether paper or electronic, respects the right to confidentiality. If you are put in a position where you are being asked to disclose confidential information, ensure that you only do so with good reason, and if in any doubt, contact your defence organization for advice.
Key points
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References |
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TOPAbstractThe GP curriculum and...A brief historyWhy is it important...What sort of information...What if the person...What sort of consultations...The pros and cons...How long do records...What safeguards should be...Who can access the...Can patients ask for...Who else can access...ConclusionReferences |
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Benson T. Why general practitioners use computers and hospital doctors do not- part 2 scalability. British Medical Journal (2002) 325:1090–93.
Department of Heath. The Caldicott Guardian Manual (2006) Accessed via www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_062722 [date last accessed 06.07.2008].
Department of Health. NHS Caldicott Guardians. Accessed via www.dh.gov.uk/en/Managingyourorganisation/Informationpolicy/Patientconfidentialityandcaldicottguardians/DH_4100563 [date last accessed 08.07.2008].
General Medical Council. Good Medical Practice (2006) Accessed via www.gmc-uk.org/guidance/good_medical_practice/good_clinical_care/index.asp [date last accessed 06.07.2008].
Hamilton W, Round A, Sharp D, Peters T. The quality of record keeping in primary care: a comparison of computerised, paper and hybrid systems. British Journal of General Practice (2003) 53:929–933.[Web of Science][Medline]
RCGP. GP Curriculum statement 2: The General Practice Consultation. Accessed via www.rcgp-curriculum.org.uk/PDF/curr_2_The_GP_Consultation.pdf [date last accessed 06.07.2008].
Savage P. A book that changed my practice, Problem orientated medical practice. BMJ (2001) 322:275.
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