This document sets the standards for general medical record keeping by physicians in hospital practice. The purpose of these standards is to maximise patient safety and quality of care; support professional best practice; and assist compliance with Information Governance and NHS Litigation Authority (CNST) Standards. These generic medical record keeping standards are applicable to any patient’s medical record.
- The patient’s complete medical record should be available at all times during their stay in hospital.
- Every page in the medical record should include the patient’s name, identification number (NHS number) and location in the hospital.
- The contents of the medical record should have a standardised structure and layout.
- Documentation within the medical record should reflect the continuum of patient care and should be viewable in chronological order.
- Data recorded or communicated on admission, handover and discharge should be recorded using a standardised proforma.
- Every entry in the medical record should be dated, timed (24 hour clock), legible and signed by the person making the entry. The name and designation of the person making the entry should be legibly printed against their signature. Deletions and alterations should be countersigned, dated and timed.
- Entries to the medical record should be made as soon as possible after the event to be documented (e.g. change in clinical state, ward round, investigation) and before the relevant staff member goes off duty. If there is a delay, the time of the event and the delay should be recorded.
- Every entry in medical record should identify the most senior healthcare professional present (who is responsible for decision making) at the time the entry is made.
- On each occasion the consultant responsible for the patient’s care changes, the name of the new responsible consultant and the date and time of the agreed transfer of care, should be recorded.
- An entry should be made in the medical record whenever a patient is seen by a doctor. When there is no entry in the hospital record for more than four days for acute medical care or seven days for long-stay continuing care, the next entry should explain why.
- The discharge record/discharge summary should be commenced at the time a patient is admitted to hospital.
- Advanced Decisions to Refuse Treatment, Consent, Cardio-Pulmonary Resuscitation decisions must be clearly recorded in the medical record. In circumstances where the patient is not the decision maker, that person should be identified e.g. Lasting Power of Attorney.