Summary

• Keeping good clinical records is essential for continuity of care, especially when many clinicians are involved in delivering care. Good record keeping is an integral part of good medical practice.
• Records should include sufficient detail for someone else to take over a patient’s care, seamlessly, from where you left off.
• Records that secure continuity of care will also be adequate for evidential purposes,in the event of a complaint, claim or disciplinary action.
• Clinical records should be clear, objective, contemporaneous, tamper-proof and original.
• Abbreviations, if used, must be unambiguous and universally understood.

• Clinical records comprise handwritten and computerised notes, correspondence between health professionals, laboratory reports, x-ray and other imaging records, clinical photographs, videos and other recordings, and printouts from monitoring equipment.
• Clinical records are sensitive personal data and must be kept securely to prevent damage and unauthorised access.
• Clinical records can usually be shared with other members of the clinical teams responsible for clinical management, unless the patient objects.
• Access to records or the information they contain is also permissible in other circumstances but the record holder must always be prepared to justify disclosure.
• All healthcare organisations holding clinical records must be registered (under the Data Protection Act) with the Information Commissioner.
• Where information from clinical records is required for audit and research purposes, anonymised data should be used wherever possible.
• Records should not be kept indefinitely but should be retained as long as they are relevant to patient care and associated legal and administrative purposes.
• Any alteration to written medical records should be immediately apparent to avoid any accusation that there has been an attempt to mislead or deceive.
• Similarly, with electronic records, any entries should be made clear to identify any changes.
• Common problems are illegibility of handwritten notes, failing to date and sign them, inaccurate recording of information and insufficient detail.