Health Records in Court

Negligence Lawyer and Fellow, Royal Society of Medicine

Introduction to health records. Legal and professional obligations. The court system. Sources of law; statute and common law. Guidelines and codes of practice. Court system. Civil law; negligence. Criminal law. Accountability. Four areas of accountability. Legal and professional obligations. Will the records stand up to legal scrutiny. Case study. Good practice for health care records. The purpose of health records. Record keeping is a chore. What constitutes a health record and a legal document. Who should write the records. When should the records be written. How much should you write. What should you write. What to include. What to leave out. Don’t keep it in your head. The detail. Inadequate detail. The rationale. Clarity of detail. Clear and unambiguous. Care and condition. Advice given. Action. Negative findings. Frequency of the entries. Spelling and grammar. Missing information. Patients’ details. Acute admission health records. How do we record?. Protocols and guidelines. Aggression. Failure by the patient to comply. Third party information. Telephone advice. Consent issues. Language and interpreters. Times and dates. Authenticate. Legibility. Designated place for allergies. Standard forms and tick boxes. Fact, assumption, professional opinion. Amending the records. What to avoid. Jargon. Routine and meaningless phrases. Gratuitous entries. Subjective comments. Abbreviations. Don’t squeeze information in. Don’t leave gaps. Errors in the health records. Common errors in the records. Transmitting and receiving information. Duplication of health records. Sharing information. Inter professional access to records. Communication between health professionals. Confidential information. Records used for research and teaching. Records used for clinical audit. Access to the health records by the patient. Patients’ right of access to health records. Copying letters to patients. Systems and retention of records. Systems of record keeping. Supplementary records. Electronic records. Further considerations. Infection control and the records. Mental health records. Midwifery records. Social care records. Ownership and storage of records. Who owns the health records. Storage of health records. Health records used to prepare witness statements and reports. Health records used as evidence. Will the record stand up to legal scrutiny. Untrue or false records. Missing records. Lack of professionalism. What the is court looking for. Defensive records. Assessment criteria for health records. Glossary.