Patient record keeping: an overview of areas central to good practice

Ensuring good practice in patient record keeping is essential in the delivery of healthcare. Here we provide an overview of areas that are central to effective practice in record keeping.

NHS England guidance – ‘Digital Primary Care: The Good Practice Guidelines for GP electronic patient records’ - highlights that patient records of high-quality “are the foundation of good clinical care delivery” and the delivery of  “safe and efficient patient care depends on having high quality patient records…”.

Evidential importance of medical records

In the event of a complaint, inquest, clinical audit or claim, the quality of the records kept will be an important factor in the assessment of the quality of care provided. The medical records are the best evidence of what was done or not done.

Often working under pressure, it can be challenging for clinicians to maintain the right balance during an assessment between good medical record keeping and good communication with the patient. However, it is one that clinicians must tackle as  inaccuracies or missing information in a patient’s records can preclude the successful defence of a claim.  

Medical records: written, verbal and digital information

The process of patient record keeping is one that is becoming increasingly digital, but remains a hybrid one that continues to involve handwritten information.

It is important to remember that the same principles apply whether the information is being captured in writing or digitally. As NHS England’s guidance provides, the primary purpose, “whether hand written or digital, is to support direct patient care”.

Medical records now consist of information that is captured from a variety of different formats, which include (in addition to hand written clinical notes):

• Verbal/in-person meetings and conversations between staff, and between clinicians and patients
• Telephone conversations and conversations held via video-calls with patients.
• Emails and text messages
• Photographs
• Test results, scans, and imaging.

Complaints correspondence should not be kept with the patient’s records as it is not directly relevant to the patient’s care.  

Good practice in record keeping – General Medical Council Guidance

The General Medical Council’s (GMC) ‘Good medical practice’ guidance, which came into effect on 30 January 2024, states that practitioners “must make sure that formal records” of their work, which includes patient records, “are clear, accurate, contemporaneous and legible”.

The GMC’s guidance also provides helpful information on good practice in record keeping in terms of what the records should include. In addition to documenting “relevant clinical findings”, the “drugs, investigations or treatments proposed, provided or prescribed”, and “who is creating the record and when”, it includes other information in relation to discussions held with the patient. For example, documenting “concerns or preferences expressed by the patient that might be relevant to their ongoing care, and whether these were addressed” and “decisions made, actions agreed (including decisions to take no action) and when/whether decisions should be reviewed.”

Patient access to their medical records, redaction and third parties

Patients have access to their records and it is important that clinicians avoid making entries that may undermine the clinician/patient relationship and damage their credibility if the records are used in evidence.

The NHS England guidance which is part of the ‘Digital Primary Care: The Good Practice Guidelines for GP electronic patient records’ ‘Good practice guidelines for GP electronic patient records’ provides that prior to information being “shared with the patient, sensitive information which could be seriously harmful to a patient or is about a third party should be assessed and a decision taken about whether or not to redact it.” It adds that what is considered “‘serious harm’ is a matter for clinical judgement and will vary from patient to patient.”

Information certainly cannot be redacted to hide an error or omission or to protect a health or social care provider from criticism. If the decision to redact sensitive information in a patient’s records has been made on the grounds the information could be seriously harmful to a patient,  the reasons for this must be fully recorded in the notes (and also redacted). Clinicians and carers are not third parties. If a third party consents then information about them can be released, however, if not it must be redacted. An example of third-party content is a letter referring to the patient and a member(s) of their family.

Restrictions on the amendment of medical records

The NHS England guidance provides that records should not be amended, save for in the limited circumstances set out in the guidance. The examples provided are where the information recorded is incorrect, the information relates to a different patient and has been entered in error or where the “patient has challenged the content and the challenge is considered appropriate.”

Clinical patient data is considered special category data under the UK General Data Protection Regulations (GDPR) and Data Protection Act 2018. Accordingly, patients have the right to rectification of inaccurate personal data without undue delay.