New standards for generic medical reporting have been developed by the Royal College of Physicians health informatics unit (HIU) and supported by NHS Connecting for Health.
The college says that the purpose of the standards is to maximise patient safety and quality of care, support professional best practice and assist compliance with information governance and NHS Litigation Authority standards.
There are 12 generic record keeping standards listed in total, that the college says are applicable to any patient’s medical record.
Professor Iain Carpenter, clinical lead for records standards at the RCP Health Informatics Unit, said: “Standards that can be applied to medical record keeping are an essential component of ensuring patient safety and best quality of care. These generic standards reflect the views of the medical profession and Department of Health.
“They represent the first steps in a programme supported by Connecting for Health, establishing professional standards for all components of medical records which are increasingly important with the advent of the NHS Electronic Patient Record.”
A spokesperson for the RCP added: “The quality of medical records is fundamental to the quality and safety of patient care, but at present there is no one agreed medical records standard in the NHS – each hospital has its own way of recording patient information.
“Mistakes and missing information in records are common and are a major contributory factor in medical errors and poor clinical care, leading to complaints and medical negligence cases.”
The process of developing these standards originated from a 2003 review for the RCP’s Clinical Medicine journal.
Information about the standards is being disseminated through the RCP to NHS trusts, and is being sent out as National Guidance through the Department of Health’s Communications Directorate. The HIU is now developing an audit tool so that hospitals can measure how accurate and effective their records are.
Professor Martin Marshall, deputy chief medical officer for the Department of Health said: “Adherence to these common sense standards will deliver benefits to both patients and clinicians and will clearly demonstrate the link between improved information governance and improved care provision.”
Professor Michael Thick, chief clinical officer, NHS Connecting for Health added: “This will be a most important step towards standardisation, which in its turn will ensure unambiguous communication and safety. I also look forward to the next step, which will be a continued collaboration between CfH and the Royal Colleges to produce electronic messages to support this.”
The standards have also been approved by the British Medical Association and the Medical Defence Union.
Dr Vivienne Nathanson, director of professional activities at the BMA said: “Medical records are fundamental to good clinical practice. Decisions in relation to patient care have to be clearly recorded and structured if we wish to provide a consistent account of when, why and what was agreed between a patient and their medical practitioner. Clear records are also vital to the important issues of safety and confidentiality.”
Dr Catherine Wills, Medical Defence Union (MDU) medico-legal adviser, added: “Records are primarily intended to support patient care but we also receive a number of requests for assistance with cases where problems with the medical records make it difficult to respond effectively or provide a successful defence on behalf of our members.
“The cases we have provided illustrate the importance of ensuring there are detailed, accurate and contemporaneous records – primarily for the care of the patient but also because at some future time, the records may be important medico-legally.”
The RCP is now looking at standards for the structure of admission, handover and discharge records for incorporation into the electronic patient record.