What are patient medical records?
Patient medical records are records in a variety of forms including observations, test results, and x-rays. They are both formed and maintained by healthcare providers to keep track of a patient’s medical history to ensure best practice.
It is essential that healthcare providers follow both ethical and legal requirements when making an entry to a patient’s records. Even more so now patients have the right to request, access and challenge their own records.
Recording any appointment and treatment discussed is paramount to present transparency between both healthcare providers and the patient themselves, if not, it can reflect negligence and poor quality of care.
Why is it important to keep accurate patient records?
Keeping patient records is one of the best ways to show continuity of care and receive better patient outcomes.
It is crucial to keep records updated to create a bank of evidence of care, advice, and treatment given. Having patient records consistently managed and updated is important to provide quick and easy access for healthcare professionals to deliver the right care in real time and ensure the patient’s needs are met comprehensively.
Keeping detailed patient records is also important when reporting to the Care Quality Commission (CQC) to ensure all standards are being met.
The most important aspect of keeping accurate patient records is effective communication. It is essential records can easily be picked up by another colleague without limiting the quality of care a patient receives.
What do patient records need to include?
- Each patient record should contain an identification section containing personal data e.g., name, age, address, next of kin.
- On admission, the patient’s blood pressure, pulse, height, weight, lifestyle choices (e.g., if they are smoker) and any other test results should be included.
- All medication given to patients needs to be recorded and signed on prescription sheets.
- If notes need transferring due to patients moving away and joining a new GP practice, consent forms need to be signed.
- For clinical records the name of the healthcare professional and the date should be included in each new entry. Any relevant clinical findings discovered and the patient’s reaction to their treatment should also be included.
Tips on maintaining good patient records
There are lots of quick and simple things you can do to maintain good patient records. We have pulled together some of the best tips on maintaining good patient records from various experts such as: NHS information governance, the Department of Health and the General Medical Council.
- Ensure staff are clear on following requirements to create and maintain patient records, especially when supervising another healthcare professional e.g., a student nurse.
- Ensure staff follow both legal and ethical requirements e.g., following the Data Protection Act 1998 and General Medical Council’s guidelines on ethical requirements.
- Ensure all the correct information is included in each entry and personal information is updated when it is needed.
- Write your entries as soon as possible after the appointment or treatment if it is not possible during it.
- If a record is written ensure it is dated and signed. If it is a digital entry, make sure it can be traced back to the user that created it.
- Complete all entries with accuracy and without any false information or assumptions.
- Involve patients in establishing their records and how they feel about different treatments, so they feel understood and heard.
- If a record needs to be edited, make sure the original entry is still visible.
- Make sure records are stored securely and guidelines on destroying patient records are followed.
- One of the most crucial tips is to make sure all entries are clear and legible. Make sure it is standardized with no jargon or abbreviations so both other colleagues and patients themselves can read and understand them. All entries must be in chronological order to ensure the best continuity of care.
Importance of maintaining good patient records – staff changeover
Due to the logistics in the healthcare system, other healthcare professionals taking over where you last saw and treated a patient is likely. There are some key things to remember to make sure the handover is smooth and does not limit the quality of care a patient receives.
- Make sure all records are fully up to date so the next colleague can fully understand the treatment or medication a patient is receiving.
- Make sure records are stored and can be accessed easily to save time.
- Make sure records are filed in the correct place, especially once a patient has been discharged from treatments.
- If anything has been stored in a different place, make sure the whole team are aware to stop time being wasted.
Maintaining good patient records with EPR
Being time efficient with patient records is key in both forming and maintaining them. With waiting lists continuing to grow and pressure on GPs and hospitals building, methods of reducing time spent on administrative tasks to access patient records quickly are heavily needed.
The best way forward is using electronic patient records (EPRs) to save time, capture, store, use, and share information easily. Find out more about what is an electronic patient record management and how you can use it to save time and reduce errors.
Electronic Patient Records are now spreading beyond larger NHS trusts meaning all organisations providing care can benefit from systems designed for clinical use.
With electronic patient records, healthcare professionals have all the information they need at their fingertips and can update notes wherever they are, saved back to the system in real time.
Rio Cloud, our electronic patient record system, allows a great opportunity to save time and help healthcare professionals provide better care with all the information they need.