Evidence on the quality of medical note keeping: guidance for use at appraisal and revalidation

Key recommendations

• All clinicians have a degree of responsibility for the overall state of medical records. However, this is limited where, for example, the medical notes folders are in poor condition, disorganised or unavailable. In these situations, trust management must hold responsibility, and a consultant may reasonably be expected to inform trust management when these situations arise. Only in this way will the general standard of medical notes folders be improved.
• Appraisal for revalidation may include information on the quality of medical note keeping in support of the appraisal process.
• Information from an audit against professional standards, such as those approved by the Academy of Medical Royal Colleges, can be used as appropriate evidence, irrespective of who conducts the audit.
• Information from an audit should not be required information; rather it should be an option, unless concern has been expressed about the medical notes entries of a consultant or the notes of patients under their care.
• A general question about medical record keeping is a legitimate component of 360⁰ feedback. This should be a general question and not a specific question about performance against specific standards or results of audits.
• Revalidation is intended to be a non-onerous process. However, inclusion of information from at least one audit of the medical notes could be available as supporting evidence at appraisal in any one five-year period. Patients and carers believe that this should be a required audit, irrespective of other audit requirements.
• For consultants who have responsibility for hospital inpatients, either under their name or as part of a clinical team: Information from an audit of the notes, against the Academy of Medical Royal Colleges generic medical record standards, should be from patients who have been under the care of the consultant or their clinical team (including junior medical staff). The information can come from an audit undertaken by the consultant themselves, a member of their clinical team, or the trust audit department. A consultant should have some means of determining that the notes made by members of their clinical team for whom they have a management responsibility (as a team member or as educational or clinical supervisor) are up to standard. This may be by raising the matter at a supervision meeting for example. Where they have no management responsibility for the person making the entry, then they can be expected to inform that individual or their supervisor when an entry does not meet acceptable standards. Where a consultant has no management responsibility, or there are constraints on the extent to which they are able to exercise their responsibility for clinicians who have made entries that do not meet the standards, then it is reasonable to expect that the consultant would have informed the individual(s) concerned or that person’s supervisor.
• For consultants who see primarily outpatients only: Typed letters form the bulk of the clinical communications in outpatient clinics, and they should be regarded as the primary source of clinical information. An audit of the notes of outpatients made by a consultant should be quality of the written information only. Generic Medical Record Keeping Standards 2 and 6 are the only standards that currently apply to outpatient records. Where the typed letter is the full record of the outpatient encounter, the written record is of less importance (eg entries should be dated but need not be timed or completely legible).
• For consultants who do not have patients specifically under their care (eg anaesthetics, haematology): For specialties that contribute to the care of patients under other consultants and clinical teams (including junior medical staff), the consultant may bring a sample of entries selected by another clinician from their specialty.
• For consultants who work in multidisciplinary teams where there is no clear identification of lead responsibility: An audit against the Academy of Medical Royal Colleges generic medical standards of the notes of patients who have been cared for by the team (including junior medical staff) may be used as evidence. Interpretation of the information in the notes should form the basis of a discussion. As a team member, the consultant will have a role, in so far as they feed back to members of the team on the performance of the whole team, and possibly to some individual members.