Pitfalls in record keeping

All patients have a right to access their clinical records. They are also entitled to challenge the validity of records and have factual errors corrected. An important point regarding recording consultations is to never include something that you as a pharmacist would not want the patient to see. A common complaint in hospitals and general practice is where judgemental or rude remarks about the patient have been made in the clinical record.

Some decisions may be subject to scrutiny or there could be medico-legal concerns if things have gone wrong. A general rule of thumb is that, in the eyes of the law, if a detail is not recorded it cannot be proven to have happened. This includes failure to record important negative findings (e.g. “not pyrexial”; “no vomiting”).

Records have to be thorough with particular reference to safety-netting guidance provided where advice on when further help might be required has been given. In the absence of such details being recorded, a patient’s account of the consultation is taken at face value and may be hard to disprove.

Many GPs and hospital doctors now provide patients with a copy of the consultation record. This enables the patient to check what has been recorded during the consultation and allow any corrections in interpretation. It also facilitates a common understanding in terms that the patient would use, rather than medical jargon. This is something community pharmacists may wish to consider.

Changing the record at a later date (i.e. retrospectively) based on concerns or adverse outcomes is not allowed and is illegal. Recording additional information is permissible if a pharmacist wishes to add something to the record or make a correction at a later date. The date of the amendment should be recorded and also the pharmacist’s name.

This is important as it means any changes are clear on the record and nobody can be accused of altering or tampering with the information.