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Guide to good medical records

Dr Tony Grewal provides advice on how to ensure you include all the essential data about the patient.

Keeping good quality electronic records can save time in the long run (Photograph: Jason Heath Lancy)
Keeping good quality electronic records can save time in the long run (Photograph: Jason Heath Lancy)

Medical record-keeping has come a long way since the 1960s when we needed merely to write the date we saw the patient, the diagnosis made and the drugs prescribed.

If any GPs reading this think that is all we still need to record, then please get yourself to a patient notes workshop as soon as possible.

Multiple agendas
Today's medical record has to address the requirements of multiple agendas and agencies. Making a clinical record (and aide memoire) remains paramount, but we must also consider the patient, continuity, clinical reasoning, safety-netting, performance management, legal requirements and the plethora of audit and research now expected of GPs.

There are compelling reasons why medical records must be full, accurate and contemporaneous but to meet the exacting needs of all these in detail would take far too long.

Hunting for an elusive Read code and explaining your clinical reasoning for a diagnosis can easily take 10 minutes on top of the consultation. That means there are decisions to make about what to enter and what to leave out if you are to avoid burning out through overwork.

Don't forget to include
The basic items to include are date, time, place, clinician seen (you), who was there, what type of consultation/encounter, the problem and/or diagnosis and finally, the actions taken and follow-up.

These basics alone can take the seriously technologically challenged GP a good five minutes to input, so what about all the other elements?

These cover the patient's concerns, ideas, expectations; details from the patient's clinical history, information given (written/verbal), background, important negative responses/clinical findings, relevant positive findings, decision-making process and reasoning, patient satisfaction/compliance, medication, interactions/side-effects considered, investigations, follow-up, responsibility for follow-up, safety-netting, consent and so on.

I use four simple questions to help me decide what to include and what to leave out (see box).

Decide on data to include
  • What do I need to remind me how to pick up where I left off?
  • What would a colleague need if the patient's next appointment is not with me?
  • What impression will the record give if viewed by a medical adviser, the Care Quality Commission, a lawyer or the GMC?
  • What do I need to include for other tasks (referral, reports, summary, QOF, clinical audit)?

Electronic records
For better or worse, electronic records are a fact of life and my advice to anyone who does not like them is to learn to type more quickly and accurately.

Keeping good quality electronic records can save a practice considerable time when it comes to audits, recalls or calculating QOF achievements. Basically, the only significant problem they cause is as a block in our daily consultations: very few GPs can maintain 100 per cent contact with the patient while entering notes.

I have found the best way to deal with this is to focus on the patient as much as possible during the consultation and try to finish updating their notes before the next knock on the door.

You may be more adept at typing and keeping eye contact, but essentially each of us must find a method that works for us.

Do not however delay updating the records with the data you could not manage to include while the patient was in the room. You risk finding you cannot remember the details properly. This may be unfortunate not just for the patient but also you if there is a complaint and the details needed to exonerate you were not recorded.

IT 'hygiene'
A danger associated with computer records is the ease with which a record may be 'tagged' to a login ID by the computer regardless of the user.

You must be fanatical about computer 'hygiene'. You should always log off, never share cards/passwords, ensure that the person responsible for an entry is identified, and the type of encounter (face-to-face, telephone, third party, administration, prescription) is clear.

Each entry has an ineradicable date, time and person attached as part of the audit trail. Always include an explanation for late or third party entries, and ensure the encounter date and the entry date are clear.

Read codes
These codes are necessary if the computer is to do its job properly. So, you should use a combination of narrative and codes, and ensure you cover the core elements of diagnosis/problem, and basic clinical data (BP, smoking status, and so forth).

A cynic might say: 'If it scores QOF points, use a Read code, if not, do whatever is quickest.' Read codes will become crucial if summary care records (or equivalent) are rolled out across the country and if they manage to properly address the vexed issue of practices and hospitals working on different systems.

Read codes can cause even the busiest GP to smile. My most esoteric code so far is for 'RTA, hit by tram, speaks fluent Swahili.' I am not joking.

CPD IMPACT: earn more credits
These further action points may allow you to claim more credits.
  • Look back at the last 15 medical records you updated on computer to check if they have all the information that another clinician would need to pick up where you left off; consider repeating the exercise as an audit three to six months later.
  • Double-check if the Read codes you used are accurate.
  • Do not alter the contemporaneous record if there are omissions or errors, but add a dated note with additional/correct details.
  • Make a list of data to always include and keep it somewhere easily accessible/visible.

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