Medical records are complex collections of data, commonly distributed, and serving many functions some of which conflict with each other.
Records need to be structured to a degree, but also to present a narrative.
- As (part of) the Clinical Record
- Research - take care as this is covered by legislation that is quite restrictive
- Aiding recollection
- Medicolegal - if it was not documented it did not happen (or you will find it very hard to prove it happened !)
- Complaints - Nicest is when the medical record completely demolishes a complaint about informed consent.
- Reality check... Always fascinating examining a medical record going back 50 or more years and seeing what our predecessors got away with, that the combination of technological advancement, patient and cultural expectation and medicolegal developments would render totally unacceptable today. Yes, those doctors of old did have much less bureaucracy to cope with, at least with regard to medical record keeping.
Although repeated to the point of tedium, many entries into medical notes fall down on basic standards. Each sheet of paper in a medical record should have the:
- Patient's name
- Date of birth
- A further unique identifier (In UK, NHS number will be a requirement, was formerly hospital number or address. Scotland use a CHI number).
Each entry should have the date and time and should be legibly signed, together with, where available, bleep number. In paper records, it is sometimes a good idea to use a stamp with these details: but there must still be a signature to certify this is your entry. A standard format to entries helps to ensure sufficient information is recorded.
The requirement for black ink appears to be stipulated by standards laid down by the NHS Litigation Authority (NHSLA). Where hospitals are able to meet these standards, they are able to reduce the cost of the premiums of the hospital equivalent of medical indemnity (Clinical Negligence Scheme for Trusts).
The exact rationale for this requirement is unclear. One disputable explanation is that blue ink does not photocopy as well as black ink. Another explanation is that the process of photoreduction, where medical notes are photographed on to small negatives, does not cope as well with colour reproduction of non-black inks.
Writing with fountain pens is sometimes frowned upon on the basis that ink can fade, smudge or get washed away if wet, but this does not take into account permanent inks such as Mont Blanc Permanent Blue-Black and Noodler's 'bullet-proof' series.
The concept of the Problem Oriented Medical Record goes back to 1968 and was introduced by Lawrence Weed. The 2 original elements of the POMR were:
- The list of the problems
- A specific method of structuring of the data gathered at the consultation.
The list of the problems is the foundation of the file. It contains all the diagnoses and significant states potentially useful to know for the continuity of care. For each problem, the dates of beginning and end are noted. The list of the problems is at the same time a summary of patient's history, a reflection of the current situation (active problems), and contents of the file.
The next part of the POMR is the method suggested to record the data during the consultation, summarized by the acronym SOAP.
- Subjective - the patient's observation
- Observation - the physician's observation
- Assessment - the physician's understanding of the problem
- Plan - plans goals actions advice etc
Access to Records
Accesss to medical records is governed by specific legislation, and access should only be given if the legal criteria are met. The BMA has guidance.
Two important pieces of legislation are: