The HIU has developed Generic Medical Record Keeping Standards for physicians that are applicable to any patient’s medical record. Twelve standards received formal RCP approval from the Royal College of Physicians Clinical Standards Board meeting in March 2007 and were published in the RCP journal ‘Clinical Medicine’ in August 2007 and HSJ.
Generic Record Keeping Standards (PDF 41kb opens in new window)
Background
Medical records are an integral part of effective patient care. They are used not only for primary clinical purposes but also for secondary purposes including reporting the activity of hospital services, monitoring performance of hospitals and for research. They remain the most important focus of any patient complaint or litigation.
Problems with the structure and content of medical records and record-keeping were reported by the Audit Commission (1995 and 1999), highlighting the need for improved practices and standards.
The Royal College of Physicians (RCP) HIU audited 149 case notes in five hospitals in England and Wales in 2002 and examined the completeness, specific features of individual entries and also the quality of printed discharge summaries. There was widespread inconsistency of content and structure of records, compounded by different hospital practices that made comparisons difficult.
In order to address these problems, the HIU developed the evidence-based standards for medical record-keeping.
The Generic Medical Record Keeping Standards are a set of 12 standards applicable to all medical entries which have been ratified by the RCP. Their aim is to raise awareness of the importance of record-keeping standards for best medical practice.
The standards:
- contribute to maximising patient safety and quality of care (through improved completeness of documentation by clinicians and improved clinical performance)
- support professional best practice
- assist with compliance with the Information Governance and NHS Litigation Authority Clinical Negligence Scheme for Trusts) standards.
The Generic medical Record Keeping Standards are produced as an A4 laminated sheet and can be purchased in packs of 10. It can also be downloaded from the link below.
Audit tool
We are currently developing an audit tool to support the implementation of the generic medical record-keeping standards. This tool is currently under pilot in a number of hospital settings and will be made available online by early 2009.
Advice from the NHS Litigation Authority
Comments from the leads for NHS Litigation Authority Risk Management Standard 1.8, Governance - Clinical Records Management and 4.4, Clinical Care - Clinical Record-Keeping Standards respectively on the use of the tool (May 2008):
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The NHS Litigation Authority Risk Management Standards need to be correctly referenced, i.e. not NHS Litigation Authority (CNST) Standards – as the CNST General Clinical Risk Management Standards were withdrawn at the end of March 2006 and replaced by the NHSLA Risk Management Standards
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An organisation using the RCP standards and audit tool would need to write this into their relevant organisational procedural document, reflecting standards 1.8 Clinical Records Management and 4.4 Clinical Record-Keeping Standards (see link below); it is most important to note that, should an organisation choose to use the RCP standards and tool as part of their rolling programme of audit, then this should be very clearly reflected/referenced within the overarching approved documents for health record management (1.1.8) and/or clinical record keeping standards (1.4.4)
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You may be interested in the relevant reference sources within the handbooks accompanying our standards under the Risk Management sections (see link below)
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The attached NHSLA Statement on the endorsement / sponsorship of products and services, which appears on our website, refers to any position that the NHSLA may take around the standards and tool.
Relevant links to the NHS Litigation Authority Website:
NHSLA statement on endorsement/sponsorship (Word 32.5kb opens in new window)
If organisations have any questions about the NHSLA risk management standards and assessment they should contact their allocated assessor. Where assessor details are not known, please email riskmanagement@nhsla.com