On the record: The importance of good record keeping

For most of us, record keeping is a key part of everyday practice. Doing it well and ensuring we meet the required standards is fundamental to effective patient care. Ultimately if no record is made, the law may consider the events not to have happened.

We live in a world where hand-written notes are becoming a thing of the past and electronic record keeping is commonplace. Electronic records make handwriting misunderstandings redundant and facilitate improved communication across the healthcare systems.

Hand-held devices allow records to easily be updated on the go. Shared records and the sharing of records can greatly improve communications across the healthcare professions and improve overall patient care, while also ensuring patient confidentiality is maintained, where necessary.

The Francis Report emphasised the need for better information across healthcare. It is increasingly accepted that this challenge can only be met by the development and use of electronic health records in which data are recorded consistently across all contexts.

The government’s 10-year strategy for transforming the way that patients get and use information about their health, the Power of Information, proposes that by 2015 patients will have online access to their own GP health record.

Why is good record management important?

Good record management is the legal record of the interaction with, and assessment and treatment of, the client. Essentially, if it’s not written down it didn’t happen. It is important for effective communication with other health professionals and therefore optimal patient care.

It’s not only good records that are important but the appropriate sharing of information as highlighted by the introduction of the seventh Caldicott principle.

Physiotherapy staff have to comply with regulatory, national, professional body and local employer guidance on record keeping. Several laws govern both how the patient may have access to their records and how a professional must handle and use information.

Is it acceptable to share patient information/records with other health professionals?

The 2013 Caldicott Review in England introduced an additional principle, which states: ‘The duty to share information can be as important as the duty to protect patient confidentiality.’

The review found a strong consensus of support among professionals and the public that safe and appropriate sharing in the interests of the individual’s direct care should be the rule, not the exception.

I work in private practice. Are there electronic software packages that the CSP recommends?

The CSP advice says: clarifying that the specific technical capabilities of the system enable the required regulatory, professional and legal standards of clinical record keeping to be met that a distinction can be made between entries and authors.

In an electronic environment, this can be achieved by using individual smartcards or unique username/password logons which highlight in the record who made the entry the system needs to be secure and sufficiently backed up in case of theft or damage data storage limits should be sufficient to ensure the necessary storage and retention of records is achievable.

The CSP is not in a position to provide specific recommendations on either software or hardware for an individual business and therefore cannot recommend one provider or system over another. The Information Commissioner’s Office is a source of further information on this subject.

Is it safe to store my patient’s records electronically on the cloud?

First and foremost, you need to ensure your regulatory and legal responsibilities in respect of record keeping and data protection are met.

There are several considerations, detailed above, that should be made when deciding what format to use to record patient details.

These should be helpful with regards to assessing and ensuring confidentiality is not breached when using cloud technology, and examining and putting in place appropriate security/access/contract arrangements with the cloud provider. Look at the ICO website for guidance on using the cloud.

What is the minimum amount of time that patient records should be kept?

The CSP advises that the minimum amount of time a standard adult record should be kept is eight years.

You are advised to review the new CSP webpages on record keeping for country specific guidance on different types of records.

Is it acceptable for the physiotherapy record to be part of the medical ward record and not to hold a separate record as well?

It is becoming more common for a group of different professionals involved in the delivery of patient care to input into one shared or unified record (in either paper or electronic format). This is perfectly acceptable practice.

The physiotherapist should record the information they obtain into whatever repository their employer requires, such as the medical ward notes, as long as it gives the capacity to document physiotherapy treatment and decision making appropriately.

In circumstances where physiotherapy staff are asked to contribute to the main medical record but there is no facility to capture decision making and intervention details, then a separate record should be maintained. However, duplication of effort around record keeping should be minimised.

Who can countersign my student notes?

Whoever is ultimately responsible for the patient in question (for example the practice educator, other physiotherapist or qualified member of the multidisciplinary team) is professionally accountable for the actions of the student who is performing delegated tasks in relation to that patient’s care.

The person who is responsible for the care of the patient is the one who must provide the countersignature.

Record-keeping: More information

• The CSP's record-keeping guidance, updated in December 2014, is a useful staring point
• See also the Francis report for more information
• The ten-year strategy The Power of information
• The Caldicott review

Using this article to support your CPD

• If this article has made you think about your own record keeping, it may be time to bring yourself up-to-date on the reports that have been mentioned and how they affect your specific practice. Schedule some time to look at the updated record-keeping guidance.

• Have you audited your client records in the last year? If not, use the updated guidance to check that your records, and how you store them, comply with professional and regulatory standards and the law.

• Wherever you are in the UK, read about the seventh Caldicott principle. Although this report was commissioned in the UK it has implications across all physiotherapy practice. Discuss its implications for your local department with your colleagues or consider running a training session for your colleagues.

• Are you up-to-date with the progress being made in electronic record keeping? Review the CSP’s new webpages on record keeping along with the Information Commissioner’s Office website to understand opportunities for your business or work environment and ensure you have made all the necessary considerations for your own records.

• Having invested some time in these tasks, make sure you store the evidence of your learning, with a record of what you have learnt, in your portfolio.

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