Medical records and documents

MPS Educational Services carry out clinical risk assessments of out-of-hours providers and the following is an example of a typical scenario. Some of the facts have been changed to ensure confidentiality.

Part 1: Home consultation notes

This particular out-of-hours provider had a routine practice surrounding its doctors’ consultation notes made during home visits. This practice saw hand-written notes being later passed on to reception staff to be transcribed into the computer record; this approach represents poor practice.

Home visits by urgent care service doctors often involve very difficult clinical decisions. There is an unusually high risk of a subsequent allegation of inadequate care.

Comments

Complete and contemporaneous records are essential for the maintenance of good quality patient care and are needed if a claim is to be successfully defended. Some courts take the quality of the record as an indication of the quality of care provided to the patient.

In our experience it is common practice for out-of-hours home visit consultation notes to be recorded directly by the doctor into the service’s electronic patient records. The notes are usually typed on a laptop computer to the Adastra system in a service’s vehicle, while the doctor is driven to the next call.

Part 2: Paper documents

Many urgent care services are aiming for completely paperless clinical records. However, clinical communications from outside organisations are most frequently still received as paper – or faxed, or sent via scanned images of paper documents.

This particular out-of-hours provider had a number of different forms of paper documents, which included:

• Communications books used in the reception area.
• Faxes received on a fax machine (as opposed to faxes received as an image on a PC).
• Forms or letters used by other organisations to refer patients to the service. These would include, for instance, transfer letters from A&E or notes to the service from a care home matron.
• Hospital discharge letters brought to the service by patients.
• Written instructions from other clinicians to the service’s employed nurses with regard to dressings or injections.
• The service’s own internal hand written documents, such as the forms on which home visits are currently recorded (see Part 1).

Comments

Allegations of poor care frequently involve failures of communication between agencies or clinicians. Demonstrating the exact information available to a doctor or nurse during a consultation is often a crucial aspect of defending an individual or their employer. The absence of important documents might lead to general inferences about an organisation’s administrative standards.

Recommendations

The out-of-hours provider was issued with the following advice.

• Urgently consider changing the routine practice of receptionists transcribing the clinical notes of home visits. Doctors should record their notes as soon as possible after a home visit. Ideally these notes should be made directly into the computer clinical record. This process will produce a computer audit trail demonstrating that all doctors have produced contemporaneous clinical notes.
• As soon as possible, give doctors the facility to record consultation notes directly into the Adastra system in the service’s vehicles.
• Have a written records policy and train staff to meet the policy’s stipulations.
• Conduct an audit exercise to make sure that single identified documents can be successfully and quickly retrieved from the archiving service.
• Be certain that existing archives are preserved for at least eight years from the date of the clinical episode to which they relate, longer for some cases, eg, children.
• Ensure that staff are aware of the importance of preserving the original written clinical communications that they receive.
• Consult with a software supplier about the feasibility of attaching electronic images of documents to patients’ clinical records. This approach is now adopted almost universally in GP surgeries, but will usually require an appreciable investment in server and other hardware upgrades. If this facility can be acquired:
  • Immediately store any documents received by email or digitalised fax image within the patient record (rather than printing and archiving them).
  • Investigate systems for scanning and electronically storing the paper documents that are usually archived.