Effective clinical record keeping has always been a prerequisite of delivering high quality evidence-based healthcare. Accurate clinical records are essential for providing safe continuity of care. Medical records include electronic documents, handwritten notes, voice recordings, emails, consent forms, text messages, laboratory results, photographs, videos and printouts.

As a GP, it is essential that conversations with patients and colleagues, diagnoses you make and treatment plans you decide upon are well documented. Practitioners may find themselves relying on what they have documented in the medical records in a range of different scenarios, from clinical audits, complaints, a statement for the coroner, disciplinary proceedings or even a report to assist with the management of a clinical negligence claim. A doctor’s defence often largely relies on the evidence available in the clinical records. If essential information is missing, considered to be inadequate or inaccurate, claims may require to be settled when they could have otherwise been defended.

ET v Dr M: A case of wrongful conception

A recent High Court case in London has attracted significant attention from the media as well as many of our GP members. The importance of good medical record keeping is highlighted in this case. The clinical negligence claim was brought by the claimant, ET, versus Dr M, GP, alleging “wrongful conception”. The claimant, 20 years old, was born with lipomyelomeningocele (LMM), a form of neural tube defect. To summarise, the claimant alleged that Dr M – over 20 years ago – failed to adequately advise the claimant’s mother with regards to folic acid supplementation. It was alleged that Dr M failed to provide proper pre-conception advice about the supplementation, and alleged that had ET’s mother been properly advised, she would have delayed conception.

It was examined in the case that Dr M had recorded in the records that he had discussed folic acid with the claimant’s mother, noting: “Preconception counselling. adv. Folate if desired discussed”. Having no recollection of the consultation, Dr M relied entirely on his usual practice and notes. During the hearing, this record of discussion was explored by the judge. The judge found that Dr M’s note was inadequate, and therefore stated that Dr M was attempting to speculate or make assumptions about the discussion. The judge did not accept Dr M’s evidence and ultimately found in favour of the claimant.

It is important to highlight that, when looking at such cases, these are judged on a case-by-case basis and are fact specific.

It is understandable that GPs may be concerned and have questions regarding what this judgement means for GPs when undertaking preconceptual counselling of patients, and also what this means for the importance of record keeping generally. Ultimately, accurate medical records and good record keeping remain a key part of a doctor’s responsibilities and their importance cannot be underestimated.

What are good medical records?

Good medical record keeping means that the doctor themselves, or a colleague, can reconstruct key parts of each patient contact without relying on recollection.

The GMC, in Good Medical Practice, advises that documents made, including clinical records, must be clear, accurate and legible. The guidance further states that clinical records should include relevant clinical findings, decisions made and actions agreed, who is making the decisions and agreeing the actions, the information given to patients, any drugs prescribed or any other investigation or treatment, and who is making the record and when. The GMC guidance goes on to advise that doctors should make the records at the same time as the events being recorded (contemporaneously) or as soon as possible afterwards.

It is also advisable to document relevant medical history, examinations and relevant clinical findings (such as objective measurements), differential diagnoses, and capacity and consent. It is prudent to detail the treatment options that are discussed, including not receiving treatment, and the benefits and risks of each option. If a referral or follow up arrangements have been made, these should be documented. Doctors should ensure that they record any safety netting advice given to a patient about when to seek further review, any specific symptoms or signs that would necessitate an urgent review (‘red flags’), and they should provide details of this advice.  

If a patient is offered a chaperone for a clinical examination (whether this is accepted or not), this offer should be documented.

With regards to telephone consultations, it is important to remember that the standard of record keeping does not alter simply because the patient is not present in the consulting room.

It is not only the contents of medical records that are crucial. The presentation of records can also affect the usability and credibility of the documentation within. Doctors should ensure that records will be easily understandable when handwritten, legibly signed with the date and time. Good medical records, ideally, would avoid the use of abbreviations, as unconventional or unfamiliar abbreviations could lead to confusion and misunderstandings.

Doctors must also ensure that any records that contain personal information about patients, colleagues or others are kept securely, and in line with data protection requirements.

Good record keeping tips

• Always date and sign your notes, whether handwritten or on a computer.
• Document all decisions made, clinical findings, information given, results, consent and referrals.
• Avoid writing offensive or gratuitous remarks in the clinical records. At some point the records may be read by the patient and, in some circumstances, their family.
• Any refusal or consent to treatment must be very clearly documented within the records.
• If for any reason a retrospective entry is made, it should be clearly dated to reflect the date the entry was made, including your name.
• All medical records should be documented well, easily understandable, clear, detailed and in a structured manner to ensure continuity of care.
• Accurate and comprehensive medical records are the foundation of any medicolegal defence. Good medical record keeping should be a part of your daily practice.
• Keep in mind that patients have the right to access their own records, and right to request that factual inaccuracies or errors be rectified.

The takeaway

The recent case of ET v Dr M serves as a reminder and highlights to medical professionals the importance of ensuring that clear and detailed notes are made. With regards to this particular case, it is advisable for doctors, when providing preconceptual counselling, to ensure that they document a comprehensive note, including details of what is discussed – in particular with regard to folic acid supplementation. The note should be detailed, including the risks and benefits that are explained to the patient, along with any questions asked and answers given.

Medical Protection does understand the pressures and stresses that GPs face daily, in particular that there is limited time allotted for patient consultations. However, high quality record keeping is an important part of a GP’s consultation with a patient and should be part of routine practice, in order to best protect and defend your professional position as well as ensuring safe continuity of care.