Accurate medical records are a crucial component of good patient care in the medical field.
From ensuring your patient gets the best care possible to protecting yourself in the event a complaint is raised, you’ll want to have clear evidence detailing each interaction - all while ensuring your record management meets strict GDPR compliance and legal obligations.
To help you understand best practice when keeping records in the medical field, we’ve explained what is actually considered a medical record and the top 10 principles you need to follow to give patients the best care possible.
What is considered a medical record?
A medical record is any form of document you create to formally record your work. There are a number of different types of material that can be considered a medical record.
- Handwritten notes
- Computerised records
- Correspondence between health professionals
- Registers, including birth, death, theatre, Accident and Emergency, etc.
- Lab reports
- Images, x-rays, photographs, videos and other recordings
- Printouts from monitoring equipment
- Text or email communication with patients
When creating a medical record in any of the above formats, whether that’s physically or remotely, it’s essential that you follow good practice in record keeping to ensure the best patient care and provide evidence in case of a claim.
10 record keeping tips for medical records
1. Don’t miss the key details
One of the most important principles of good record keeping is to take comprehensive notes in the first place. In their ethical guidance, the General Medical Council lists several key pieces of information which must be included within a clinical report.
- Relevant clinical findings
- The decisions made and the actions agreed, and who is making the decisions and agreeing the actions
- The information given to patients
- Any drugs prescribed or other investigation or treatment
- Who is making the record and when.
2. Make sure records are clear, accurate and legible
According to the GMC, those creating a medical record have a professional obligation to record them in line with the Data Protection Act 2018 - meaning they should be accurate, clear and legible.
To ensure they are as accurate as possible, records should be made during the consultation or soon after, and dated.
3. Sign and date further additions or alterations
Any further additions or alterations to a record must be signed and dated. When making an alteration, any rectified information should still be legible by running a single line through it, rather than completely deleting the entry.
This good record keeping practice ensures that future clinicians have a complete picture of the information on which a patient’s treatment was based at any point in time.
4. Treat audio and visual recordings the same way
An audio or visual recording should be treated in the same way as a textual record, meaning it must be safely stored for the entirety of its retention period.
When taking an audio or visual recording, it’s essential to be completely transparent with patients about how the record will be used and what happens to the recording following the interaction (i.e. whether it will be deleted or stored).
5. Move to digital storage
As stated by the NHS Records Management Code of Practice 2021, medical organisations should be moving towards digital records.
This is because it is easier to audit access to digital records, they are quicker to file and retrieve and they take up much less storage space than physical records.
One way you can start building an electronic management system is by scanning physical documents to a secure online portal. You can learn more about how we can help on our medical document scanning services page.
6. Take immediate action when inaccurate information is discovered
There may come a time when the wrong information is filed within a patient’s electronic or paper medical record. This could include the wrong information recorded for the right patient or information filed within a record that belongs to a different patient.
If this is the case, as soon as you notice the error you must take action. Most importantly, do not delete the information from the record as treatment, care or a procedure could have been given to the patient based on this information.
See the Institute of Health Records & Information Management’s guidance on how to manage incorrect information in medical records.
7. Remember patients have the right to access their records
Under the General Data Protection Regulations, patients have the right to request access to their medical records.
They also have the right to ask for factual inaccuracies or errors to be rectified or deleted. If they do so, you have one month to respond, with the ability to extend this to two if the request is complex.
If an entry is found to be factually incorrect, a signed and dated note with the alteration should be added to the medical record. It should be clear that the alteration was completed at the patient’s request and, ideally, the incorrect information should be retained rather than deleted entirely.
8. Adhere to official retention periods
When a record is created, it must be held locally for a short period of time (such as a year) and then moved to long-term storage where it will remain until the end of its retention period.
You can find a detailed list of retention periods in the NHS Records Management Code of Practice 2021.
Once the retention period is met, records will need to be dealt with appropriately as GDPR prohibits organisations from retaining documents longer than necessary.
Understanding and adhering to the correct retention periods is the foundation of good practice in record keeping. We support hospitals and NHS trusts with retaining and disposing of documents at the right times.
9. Shred paper documents
Another suggestion by the NHS Records Management Code of Practice 2021 is to ensure an organisation’s records management process is as environmentally friendly as possible.
To do this, any paper records that have reached the end of their retention periods should be shredded and then recycled - rather than burnt in an industrial furnace.
10. Use an ISO-accredited provider to help with record management
Any organisation within the medical field must have a records management policy in place which outlines the process of organising, storing, retaining and deleting its records.
To ensure continuous adherence to changing industry regulations and GDPR, records can be managed, stored and destroyed using an ISO-accredited off-site provider such as Shredall SDS Group.