The legal importance of good medical records

If continuity of care for patients is to be assured, it is vital to keep good medical records, whether they are handwritten or electronic. Health professionals and others are able to use adequate medical records to reconstruct the essential parts of each patient contact, without the need to refer to memory. When medical notes are sufficiently comprehensive, it is easier for health professionals to carry on where a colleague left off.

 

The need for continuity of care for the patient is the main reason to maintain medical records. However, medicolegal consultants may also advise their retention in case the patient pursues a claim after a workplace injury or road traffic accident. Health professionals also find good medical records vital for defending a complaint or clinical negligence claim, given the insight that they provide into the clinical judgment that was exercised at the time. In general, if records are adequate enough for continuity of care, they will also suffice for legal use.

The key details of every patient contact should be summarised in medical records. Medicolegal consultants would advise that clinical records include not only relevant clinical findings, but also the decisions made and agreed actions, in addition to who is making and agreeing these decisions. Good clinical records also include the information that patients have been given, any prescribed drugs or other treatment or investigation and who is making the record and when. Notes should also subsequently be made on the patient's progress, alongside findings on examination, monitoring and follow-up arrangements.

The wide range of material covered in medical records can also include handwritten notes, computerised records, laboratory reports, correspondence between health professionals, photographs, imaging records such as X-rays, videos and other recordings and printouts from monitoring equipment. Medicolegal consultants advise that health professionals read the NHS's Standard for End of Life Care Co-ordination Record Keeping Guidancefor the key information that an end of life record should hold.

Health professionals are also urged by medicolegal consultants to familiarise themselves with the GMC's Good Medical Practice, which dictates that all documents made, including clinical findings, for formally recording work are clear, accurate and legible. If it is not possible to document records during (or immediately after) the consultation, they should be written up as soon as possible afterwards. Records containing personal information, whether on patients, colleagues or others, should also be kept securely and in line with any data protection requirements. Doctors are expected to comply with GMC guidance on record keeping procedures.

Additions or corrections may also need to be made to a medical record from time to time. If paper records are held, the health professional amending the record should include their name alongside the date of the amendment, so that no allegations  can be made of trying to pass off the amended entry as contemporaneous. Rather than obliterating an entry that they wish to correct, the health professional would be advised by medicolegal consultants to run a single line through, enabling it to still be read. More information can be found in our Essential Guide to Medical Records.