Why is it essential to go on the record

Medical records are at the heart of good patient care and an essential component of understanding what went wrong and why if things do go awry.

Historically, medical record-keeping standards historically have received patchy support and inconsistent application. But things are changing. The quality of a patient's hospital notes is becoming ever more important for several reasons:

• with the advent of payment by results, a high standard of clinical coding is essential - it is impossible without good medical notes;

• revalidation will almost certainly include reference to clinical note-keeping;

• comparing hospital performance - rising on the public agenda - requires good medical notes;

• poor medical notes feature in many cases of litigation;

• the advent of the electronic patient record requires a high standard and sound structure for medical notes to avoid the sort of chaos that computers can create.

The health informatics unit at the Royal College of Physicians has established a programme to develop standards for recording and communicating information about patients.

The underlying principle for this work is maximising patient safety and quality of care by supporting and improving professional best practice.

An audit of 149 case notes in five hospitals identified substantial differences in the way information was structured and organised. A subsequent literature review showed that when medical notes are standardised patient outcome benefits in a number of areas.

The literature review, notes from 50 hospital admission proformas, published standards from other royal colleges, the General Medical Council and Department of Health information governance policies all formed the basis of draft standards published on the health informatics unit website.

They include a number of components: standards that apply to all medical entries - generic medical record-keeping standards - and standards for the structure and content of the acute hospital, handover and discharge records.

Draft standards

The unit carried out two polls of practising doctors in the UK. Respondents were asked: 'Should the same, standardised headings be used in the proforma for acute medical admissions in all NHS hospitals?' Both polls closed with over 1,000 responses and showed there was overwhelming support for greater standardisation across the health service.

The first set of standards, for generic medical record-keeping, were lauched this month. They are a combination of process standards (responsibility lies with the trust) and clinical standards (responsibility lies with the physician).

They state that:

• The patient's complete medical record should be available at all times during their stay in hospital.

• Every page in the medical record should include the patient's name, their identification number (their NHS number) and their location in the hospital.

• The contents of the medical record should have a standardised structure and layout.

• Documentation within the medical record should reflect the continuum of patient care and should be viewable in chronological order.

• Data recorded or communicated on admission, handover and discharge should be recorded using a standardised proforma.

• Every entry in the medical record should be dated, timed (24-hour clock), legible and signed by the person making the entry. The name and designation of the person making the entry should be legibly printed against their signature. Deletions and alterations should be countersigned.

• Entries to the medical record should be made as soon as possible after the event to be documented (eg, change in clinical state, ward round, investigation) and before the relevant staff member goes off duty. If there is a delay, the time of the event and the delay should be recorded.

• Every entry in the medical record should identify the most senior healthcare professional present (who is responsible for decision-making) at the time the entry is made).

• On each occasion that the consultant responsible for the patient's care changes, the name of the new responsible consultant and the date and time of the agreed transfer of care should be recorded.

• An entry should be made in the medical record whenever a patient is seen by a doctor. When there is no entry in the hospital record for more than four days for acute medical care or seven days for long-stay continuing care, the next entry should explain why.

• The discharge record/discharge summary should be commenced at the time a patient is admitted.

• Advance directives, consent and resuscitation status statements must be clearly recorded in the medical record.

An audit tool for the generic record-keeping standards is also being developed.

It is the RCP's intention that these standards should not only support better record-keeping, but also assist trusts with compliance with information governance and NHS litigation authority standards (clinical negligence scheme for trusts standards).

Work on the acute admission, handover and discharge standards is well under way, in collaboration with the medical and surgical royal colleges and specialist societies, practising doctors and the British Medical Association.

For more information, click here