record KeepinG
Quick guide to
medical records
clinical records contain sensitive personal data, contributed to by a number
of clinicians over a varying period of time. Keeping them secure from prying
eyes or inadvertent disclosure is a legal as well as a professional responsibility
Why keep records? terms and comments have personal information When is disclosure
the gMc expects gps to no place in clinical records. to a third party, such more complicated?
keep clear and accurate as a solicitor, without the gMc recommends
notes detailing the relevant Ways to avoid problems the patient’s express obtaining consent before
findings, the decisions made, when handling records? consent. there is also an using patients’ histories or
the information shared, any ■ obtain a patient’s consent obligation to inform the photographs for education
drugs prescribed and other and record it, before patient whose personal and training, although this
investigations, at the same disclosing information information is being sought. is currently undergoing
time as the events you are to a third party. ■ if a court orders you to consultation. When it is
recording or as soon as ■ on rare occasions it may disclose health records necessary to use patient
possible afterwards.
1
You be necessary to disclose you should comply with identifiable information,
are professionally obliged information either without the request; but it would or it is not practicable to
to keep good records. consent or if the patient be reasonable to raise anonymise it, you should
in the event of a complaint, declines their consent. objections if the court is seek patients’ consent.
clinical negligence claim or in such circumstances seeking to compel the discussing information with
disciplinary proceedings, you should be able to disclosure of irrelevant relatives can be problematic.
the medical record will justify the disclosure, if information.
2
in general, information should
contain the factual base called upon to do so. ■ Where gps have a statutory be given to the patient who
for your defence. cases ■ Make patients aware duty to report certain can share it with their family.
can be difficult to defend that their information information, eg, notification drivers have a legal
if information is missing, will be shared among of births, deaths, obligation to inform the dvla
inaccurate or indecipherable. health professionals on a infectious diseases, certain if diagnosed with a medical
“need-to-know” basis. terminations of pregnancy – condition that could impair
What makes good ■ ensure that each practice without obtaining consent. their fitness to drive. if they
clinical records? in which you work in ■ the police have no more refuse, the gMc advises
good records will contain has a data controller right to access confidential doctors to contact the
all the information one under the provisions information than anyone dvla and inform the patient
clinician will need to take of the dpa (1998). else, except under the that they have done so.
3

over where another left ■ Be conscious of inadvertent following circumstances: in circumstances where
off; they should be clear, breaches of confidentiality, - under road traffic you think a child is at risk,
objective, contemporaneous, eg, talking loudly in a legislation, where they their best interests are
attributable and original. the reception area, checking may need the name and paramount. this may require
mnemonic SoAp is a useful that the information you address of somebody disclosure to social services
reminder of the content send by fax will be received - the patient has given or even the police. consent
that should be included: in a secure place, etc. consent to release should be obtained from
■ Subjective – what ■ do not leave records the information the parents where possible,
the patient says lying around. - in compliance with except in cases where this
■ objective – what you a court order would put the child at risk.
detect – examination When is disclosure of - in a case when consent
and test results information acceptable? is not obtainable or
1 gMc, Good Medical Practice (2006), para 3f
and g
■ Assessment – your ■ if information is disclosed declined, the public
2 gMc, Confidentiality (2009) para 21–22
conclusions – often to insurance companies, interest in disclosing the
3 dvla, At a Glance Guide to the Current Medical
Standards of Fitness to Drive (september 2007
differential diagnosis employers and people information outweighs – www.dvla.gov.uk.medical/ataglance.aspx
■ problem list and plan – involved in legal the public interest in
management and follow up. proceedings, it must be preserving it. specifically if Read MPS Guide
Be wary of using limited to the authority it is to protect individuals to Medical Records,
abbreviations that can be provided by the patient. or society from risks available in Publications
misinterpreted. derogatory ■ a doctor must not disclose of serious harm. on the MPS website.
10 sessional gp | voluMe 1 | 2009 www.mps.org.uk
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