Medical Records
Medical record keeping is an important part of any doctor’s professional work; it is even more vital out of hours. The patient contact made by a doctor working in OOH will often be the first and only time that patient is seen by that doctor. The medical record is therefore important to record the interaction in case of complaint and to facilitate continuity with the patient’s in-hour GP. There are a number of important issues that need to be recorded and it may be useful to use the template below to examine your record keeping.
This would be a good example of maintaining (or improving) quality. If you found room for improvement you could make the necessary changes and re-do the exercise, this would fit in with the GMC’s description of quality improvement activity.
A template to facilitate the data collection is available here
| Presenting Complaint | Duration of symptoms recorded | PMH Family History Social history | Drug History /Allergy status | Examination findings recorded (including –ve ones) | Diagnosis clear | Prescription or plan of action recorded | Safety netting |
|---|---|---|---|---|---|---|---|
| Y | N | N | Y | Y | N | Y | Y |
| Y | Y | Y | Y | Y | Y | Y | Y |
| Y | Y | N | Y | Y | Y | Y | N |
| Y | N | N | N | Y | N | Y | Y |
| Y | Y | Y | N | Y | Y | N | Y |
| Y | N | Y | N | Y | Y | N | Y |
| Y | Y | Y | Y | Y | Y | Y | Y |
| Y | N | N | Y | Y | Y | Y | Y |
| Y | N | N | Y | Y | Y | Y | Y |
| Y | N | N | Y | Y | Y | Y | N |
| Y | Y | Y | Y | N | N | N | N |
| Y | Y | N | N | N | Y | Y | Y |
| Y | Y | N | Y | Y | Y | Y | Y |
| Y | Y | Y | N | Y | Y | N | Y |
| Y | Y | Y | Y | Y | Y | N | Y |
| Y | Y | Y | Y | N | Y | Y | Y |
| Y | N | N | Y | Y | Y | Y | Y |
| Y | Y | N | Y | Y | N | N | Y |
| Y | N | Y | N | Y | Y | Y | Y |
| Y | Y | Y | Y | Y | N | N | N |
What do the findings tell you about your medical records?
This was an interesting experience for me, I tried to put myself in the position of not having seen the patient and to look to see if there was enough information for a doctor to glean sufficient information from the medical record to understand what went on in the consultation. I was surprised to notice at least 5 out of the twenty cases did not give a final outcome and that the diagnosis was not clear. The one area that I felt that I had not recorded information that I would have asked the patient was in the drug and past medical histories, I did not record negatives (ie no drugs or no PMH).
Are there any learning points or actions from this exercise?
Yes – I will try harder to record negatives and will include an outcome in each consultation even if that outcome is no diagnosis possible or no action taken. I will repeat this exercise next year to compare.
I understand the importance of safety netting and had the impression that I always documented this but it was missed on a few occasions so will have to be more vigilant.