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. First published in the RCP journal ‘Clinical Medicine’ in August 2007 and republished with the Academy of Medical Royal Colleges in 2008 in A Clinicians Guide to Record Standards.
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 HIU audited case notes from England and Wales in 2002 and found widespread inconsistency of content and structure of records, compounded by different hospital practices. This made it almost impossible to compare the quality of information written in medical notes. In order to address these problems, the HIU developed evidence-based standards for medical record-keeping.
The 12 Generic Medical Record Keeping Standards apply to all medical notes entries and have been ratified by the RCP.
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 Information Governance and NHS Litigation Authority Clinical Negligence Scheme for Trusts) standards.
Audit tool for the Generic Standards
We developed an audit tool to support the implementation of the generic medical record-keeping standards. This tool was piloted in a number of hospital settings and was made available online May 2009.
Advice from the NHS Litigation Authority
Comments from the leads for NHS Litigation Authority Risk Management Standard 1.4.4, Clinical Care - Clinical Record-Keeping Standards respectively on the use of the tool:
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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 1.4.4 Clinical Record-Keeping Standards; it is 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 relevant documents for clinical record keeping standards (1.4.4)
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For relevant reference sources within the handbooks accompanying NHSLA standards under the Risk Management sections, see link below.