MEDICAL RECORDS

Contents

• The paper notes
• Electronic records
• The prescription chart
• Nursing record
• Care plans or pathways of care

Importance

• The record should be available at all times during inpatient stay and for outpatient appointments
• Illegible, untidy or incomplete medical records put patient safety at risk
• Entries may be scrutinised by patient, or by others with patient’s permission

Electronic records

• Paper records are being withdrawn as electronic records become more sophisticated
• Electronic records may not include all relevant historical documents
• obtain paper records if need be

Transition

• If both electronic and paper record in use, reference an entry in one in the other

Entries

• Relevant, accurate, unambiguous, and legible
• Dated, timed, and attributable
• consider use of a stamp with name and GMC number
• electronic records should be date and time-stamped automatically and reliably
• Contemporaneous, chronological and frequent
• Always use black ink
• Never write offensive or inappropriate comments about patients, relatives, carers or staff in the notes
• including acronyms/abbreviations
• As far as possible avoid comments that can be interpreted as criticism

Correction of errors

• Cross through original entry but do not obliterate
• Do not use correction fluid
• Sign and date correction

Identity of patient

Main record

• Patient’s full name
• given name(s) first, family/surname in capitals second
• Hospital unit number(s) and/or NHS number
• Full address, postcode and telephone number
• Emergency contact details (and next of kin if different)
• GP name and contact details
• Gender, religion, ethnic origin and first language
• Confirmed allergies
• document the nature of the intolerance, particularly important for alleged penicillin allergy

Each notes sheet

• Patient’s name
• given name(s) first, family/surname in capitals second
• Hospital number(s) and/or NHS number
• Patient’s location in hospital

Clerking notes

• Date (day, month, year) and time (using 24 hr clock) each entry
• sign it, print your name and GMC number legibly with a contact bleep number
• if no bleep, telephone number and your grade

Initial clerking

• Name of admitting consultant with date and time of initial consultation
• if there is a change in the consultant with overall responsibility for the patient, record name of new consultant, together with date and time of transfer of care
• Reason for admission/referral
• History and examination and provisional diagnosis
• All treatments/interventions given 

Follow-up notes

• Record whenever you see or discuss a patient. For example:
• progress of illness
• all changes in medication
• results of all investigations
• written details of oral instructions relating to patient’s care
• all interactions with patient, relatives and/or carers
• Document events as soon as possible, and especially before going off duty
• if there is a delay, record time of event and extent of delay
• Good practice is to make an entry in records of acute patients at least daily
• if a day is missed, document why in next entry

Antimicrobial medication

• Record reason for starting and stopping antimicrobial therapy
• record any discussion with the microbiology or infectious diseases team
• If stop date not recorded on prescription chart, record date to review, both on prescription chart and in patient record
• review all empirical antimicrobial prescriptions between 48 and 72 hr when microbiology results should be available

Advance directives and resuscitation status

• Record clearly any advance directives, resuscitation status and DNAR orders
• see Cardiopulmonary resuscitation clinical justification guideline

Record before surgery

• Consent on correct consent form. See Consent guideline
• Pre-operative diagnosis or indication for treatment/surgery/investigations
• Medical care plan, including site and side of procedure
• Note the requirements of WHO checklist
• in females of childbearing age assumed not to be pregnant, record the justification for this assumption with the results of any pregnancy test
• writing “N/A” or equivalent is not sufficient nor acceptable

Operation notes

Summary

• Name of consultant responsible
• Name of operating surgeon, assistant(s) and anaesthetist(s)
• Date and time
• Title of operation
• Diagnosis made and procedure performed

Details of operation

• Incision(s) used
• Description of findings
• Details of any tissue removed, altered or added
• Clear description of procedure performed
• Details and serial numbers of implants used
• usually appropriate to attach labels from implants, which will have full tracking details
• Details of tourniquet/cross clamp times
• If relevant, antimicrobials used for surgical prophylaxis
• Details of sutures used and wound closure method
• Document any drains or packs left in situ
• Details of blood loss/transfusions
• Duration of operation

Complications

• Accurate description of difficulties or untoward events, and how they were managed

Post-operative instructions

• Write immediate post-operative instructions
• e.g. post-operative monitoring, drain management
• Always inform patient if they have been given a blood transfusion or any other blood products
• record the fact that you have told them in the notes

Signatures

• Signature of surgeon
• Signature of anaesthetist on anaesthetic record

Pre-operative information

Patient identity

• Name/ID no/gender
• Date of birth

Pre-op assessment and risk factors

• Date and time of assessment
• Assessor, where assessed
• Weight (kg)
• Basic vital signs (BP, HR)
• Height (m) – optional
• Medication including contraception
• Allergies
• Alcohol, tobacco and recreational drug use
• Previous GAs/family history
• Potential airway problems
• Venous access problems
• Prostheses, teeth, crowns
• Investigations
• Other problems
• Cardiorespiratory fitness
• ASA physical status +/- comment

Urgency as classified by NCEPOD

• ‘Immediate’ (life, limb or organ-saving)
• needing surgery within minutes
• ‘Urgent’ (acute onset/clinical deterioration of potentially life-threatening condition, threat to limb or organ, fixation of many fractures, relief of pain or distressing symptoms)
• needing surgery within hours
• ‘Expedited’ (early treatment where condition not immediate threat to life, limb or organ)
• needing surgery within days (e.g. cancer)
• ‘Elective’
• timing to suit patient, hospital and staff

Perioperative information

Checks

• Nil-by-mouth
• Consent
• Premedication, type and effect

Place and time

• Place
• Date, start and end time

Personnel

• All anaesthetists named
• Qualified assistant(s) present
• Supervising consultant anaesthetist
• Operating surgeon(s)

Operation planned/performed

Apparatus

• Checks performed
• Anaesthetic room
• Theatre

Vital signs recording/charting

• Monitors used and vital signs (specify)

Drugs and fluids

• Dose, concentration and volume
• Cannulation
• Injection site(s), time and route
• Warmer used
• Blood loss, urine output

Airway

• Route, system used
• Ventilation: type and mode
• Airway type, size, cuff, shape
• Special procedures, humidifier, filter
• Throat pack
• Difficulty

Regional anaesthesia

• Block performed
• Entry site
• Needle and aid to location used
• Catheter
• Drug, concentration and dose

Patient position and attachments

• Thromboembolic prophylaxis
• Temperature control
• Limb positions

Postoperative instructions

• Drugs, fluids and doses
• Analgesic techniques
• Special airway instructions including oxygen therapy
• Monitoring

Untoward events

• Abnormalities
• Critical incidents
• Context – cause – effect

Hazard flags

• Warnings for future care

• Commence discharge record/summary at time of admission
• Complete promptly after patient’s discharge
• discharge letters must be completed within 24 hr of discharge