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Medical records: Which path will you take?

Dr Graham Howarth, MPS Head of Medical Services (Africa), and Gareth Gillespie show how the course of your career can hinge on your record-keeping

It is, perhaps, easy to be flippant about a medical record.

You may think of it as a bureaucratic sideline to the buzz and unpredictability of practising medicine; a tiresome, superfluous chore that is carried out to keep the suits in the Medical Council happy.

But to underestimate or disregard altogether the importance of keeping good medical records is to potentially deal a severely damaging blow to your career. 

To underestimate the importance of keeping good medical records is to potentially deal a severely damaging blow to your career

Whether you have received a complaint or a claim for clinical negligence, or you are at an inquest, the presence of a complete, up-to-date and accurate medical record can make all the difference to the outcome.

In this article, we have drawn on three real MPS cases in South Africa (with some facts altered to preserve confidentiality) to demonstrate how good record-keeping can shape your professional future. 

Scenario

Dr V received a request for a copy of a patient’s records from a group of attorneys; he didn’t feel he was at risk so he disclosed the records without informing MPS. Two years passed before he received a summons.

Realising he was to be the subject of a clinical negligence claim he then contacted MPS for assistance and our lawyers requested a copy of the patient’s records. By this time, Dr V had forgotten the original request from two years previously so when he reviewed the records prior to sending them to MPS, he realised they were somewhat scanty and decided to embellish them. Dr V had no intention to mislead, but he wanted to add extra clarity for the lawyers, and enhance his own reputation to the defence team.

One year later, MPS started to prepare a defence based on the records disclosed to us; our case collapsed when our “original” records were compared to the claimant’s copy of the true original records.

Had Dr V not tampered with the records, this would probably have been a defensible claim.

Learning points

This case demonstrates the value of keeping detailed and accurate contemporaneous medical records. There is a popular misconception that no – or very scanty – records can work in your favour and make a case difficult to prosecute. This can be the case but it is also more difficult to defend a case – where it might be difficult for the claimant to show there was negligence, it makes it just as difficult for MPS to show that the patient was managed appropriately. The adage “no records, no defence” has a ring of truth to it.

Furthermore, if you need to add something to a medical record or make a correction, make sure you enter the date of the amendment and include your name, so no-one can accuse you of trying to pass off the amended entry as contemporaneous.

There is only one thing more damaging than absent or poor notes and that is fabricated notes

Do not obliterate an entry that you wish to correct – run a single line through it so it can still be read. There is only one thing more damaging than absent or poor notes and that is fabricated notes.

You must always inform MPS if there has been a request for records where there is even a remote risk of litigation.

Why are they important?

You are obliged by the HPCSA to keep adequate medical records – whether electronic or handwritten – as they are essential for the continuity of care of your patients. Adequate medical records should be comprehensive enough to allow a colleague to carry on where you left off.

The HPCSA defines a medical record as “any relevant record made by a health care practitioner at the time of or subsequent to a consultation and/or examination or the application of health management”.1

The main reason for maintaining medical records is to ensure continuity of care for the patient. They may also be required for legal purposes if, for example, the patient pursues a claim following a road traffic accident or an injury at work. For health professionals, good medical records are vital for defending a complaint or clinical negligence claim; they provide a window on the clinical judgment being exercised at the time.

What are medical records?

This probably sounds like an obvious question. However, medical records cover an array of documents that are generated as a result of patient care. According to the HPCSA, these include:

“2.1.1 Hand-written contemporaneous notes taken by the health care practitioner.

2.1.2 Notes taken by previous practitioners attending health care or other health care practitioners, including a typed patient discharge summary or summaries.

2.1.3 Referral letters to and from other health care practitioners.

2.1.4 Laboratory reports and other laboratory evidence such as histology sections, cytology slides and printouts from automated analysers, X-ray films and reports, ECG traces, etc.

2.1.5 Audiovisual records such as photographs, videos and tape-recordings.

2.1.6 Clinical research forms and clinical trial data.

2.1.7 Other forms completed during the health interaction such as insurance forms, disability assessments and documentation of injury on duty.

2.1.8 Death certificates and autopsy reports.”2

Medical records cover an array of documents that are generated as a result of patient care

The essentials

Good medical records summarise the key details of every patient contact. The HPCSA states that the following minimum information must be included in a patient’s medical record:

  • Personal (identifying) particulars of the patient.
  • The bio-psychosocial history of the patient, including allergies and idiosyncrasies.
  • The time, date and place of every consultation.
  • The assessment of the patient’s condition.
  • The proposed clinical management of the patient.
  • The medication and dosage prescribed.
  • Details of referrals to specialists, if any.
  • The patient’s reaction to treatment or medication, including adverse effects.
  • Test results.
  • Imaging investigation results.
  • Information on the times that the patient was booked off from work and the relevant reasons.
  • Written proof of informed consent, where applicable.3

Medical records must be:

  • Objective recordings of what you have been told or discovered through investigation or examination
  • Clear and legible
  • Made contemporaneously, signed and dated
  • Kept securely.

Abbreviations

Although abbreviations are a time-saver, you should take care to use them only where their meaning is unambiguous and would be easily understood by your colleagues.

Although abbreviations are a time-saver, you should take care to use them only where their meaning is unambiguous

Be aware, also, that patients may access their records – it is essential that you avoid insulting or derogatory remarks, which have no place in a clinical record. The HPCSA says: “Self-serving or disapproving comments should be avoided in patient records. Unsolicited comments should be avoided (i.e. the facts should be described, and conclusions only essential for patient care made).”4

Conclusion

The standard of your record-keeping can make all the difference with regards to a clinical negligence claim being successfully defended, and will provide a rigid back-up in any HPCSA investigation.

In the next edition of Casebook we will look at the law surrounding the disclosure of medical records – both to patients and third parties. For more comprehensive information on record-keeping in South Africa, read the MPS booklet Medical Records in South Africa: An MPS Guide.

References

  1. HPCSA, Guidelines on the Keeping of Patient Records, HPCSA: Pretoria (2008)
  2. Ibid
  3. Ibid
  4. Ibid
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