COVID-19: the need for medical records to reflect unprecedented events
All NHS staff, whether working in hospitals, primary care or in the community, are working under enormous pressure during the current pandemic. Services and care pathways have been re-imagined, often at speed, to expand capacity and best meet new clinical demands. In the face of such change, comes the necessity to ensure a robust audit trail. This applies as much to service reorganisation as to treatment decision-making.
It is important that the medical records themselves fully reflect the clinical issues and problems faced and the reasons difficult decisions may need to be made. Clear and accurate information about the circumstances and basis upon which decisions are made is vitally important if, perhaps many months or years later, those decisions are challenged and investigated.
Sadly, previous experience shows increased mortality rates amongst both infected and non-infected patient groups during pandemics of this nature. Increased mortality and morbidity can be reflected in increased claims and enhanced scrutiny by coroners and regulators. Steps should be taken now to protect NHS organisations and private healthcare providers against future claims and to ensure they are equipped to respond to future factual investigations.
All healthcare clinicians are familiar with the professional guidance on good note keeping and the necessity for this has never been greater. There may be particular challenges when updating records in A&E and ICU/HDU in particular:
- Staff unfamiliar with these working environments may not have received the standard induction on how to use specific electronic patient record systems.
- Staff shortages and increased clinical demands can lead to ‘cutting corners’ when recording patient care.
- Personal protective equipment may prove a physical barrier to accessing note keeping devices.
- Staff working under stressful and physically uncomfortable conditions may be susceptible to errors in note keeping.
Governance arrangements will need to be sensitive to these pressures whilst ensuring the standard of record keeping does not drop during these times and the excellent care being provided is being recorded. IT server capacity will need to be carefully monitored to ensure no continuity issues, and steps taken to ensure an adequate supply of IT hardware and devices for note taking at ward and practice level.
As the demand on resources increases, it is sadly inevitable that this will have an adverse impact on the treatment of other patients. Routine and non-essential surgery has been cancelled or postponed for an indefinite period, patients already in hospital or admitted via A&E may be competing for resources that are becoming increasingly scarce. It is also likely that clinicians will be required to work outside of their usual disciplines.
If a medical practitioner’s ability to treat a patient is restricted, directly or indirectly, by COVID-19 this needs to be clearly detailed in the medical records. This may be in terms of the investigations that a practitioner would usually request, the commencement of chemotherapy, how quickly the practitioner would aim to operate, or the availability of a full theatre team with all necessary expertise and equipment.
Restrictions in treatment may also relate to the investigations that can be performed such as bedside ultrasound/ECG bloods and microbiology tests, and the availability of certain medical staff and monitoring equipment. The nature and reason for the restriction or delay in the treatment provided should be clearly recorded. This applies to all those providing care and treatment both in hospital and in the community.
By way of example:
“Patient requires urgent surgery for ‘x’, theatres all occupied with COVID-19 patients, no Anaesthetists available. Escalated to [clinical lead]. Patient on priority list for standby theatre ASAP. Patient and family informed and aware.”
Another consideration is for the medical records template for all patients being treated at this time to include standard wording on each page, perhaps as a footer, with words such as:
“This clinical encounter is taking place during the ongoing COVID-19 global pandemic. This may have an impact on the speed of diagnosis and treatment and the resources available for such.”
In respect of NHS patients transferred to a private healthcare provider, the reason for transfer, or indeed the reason transfer is not appropriate when available, should be noted. For these transferred patients, we would recommend clearly marking their admission form ‘NHS patient – COVID-19 transfer’, so if their care is investigated at a later date it is clear the basis on which they were treated.