Making records at the time of consultations is an accepted part of good practice. The GMC advises in paragraph 19 of 'Good medical practice' (2013) that, 'Documents you make (including clinical records) to formally record your work must be clear, accurate and legible. You should make records at the same time as the events you are recording or as soon as possible afterwards.'
There are two main reasons why it is important that contemporaneous records are made wherever possible. Firstly it helps to ensure good continuity of care for the patient. It is possible that if there is a significant delay in making an entry in the clinical records, another doctor may see the patient in the interim period and not be aware of the circumstances of the previous consultation.
Secondly, it puts the doctor in the best possible situation to respond fully to a complaint or defend them if a claim is brought about the care they provided.
However, the real world is not always as accommodating as we might like, and clearly there will be occasions when a doctor will be unable to enter data into the records at the time they're made. This might happen if a computer system is temporarily down, or when a home visit is made with no access to a remote connection to the surgery computer or laptop.
If it is not possible to enter data electronically within a reasonable period of time, then it would be good practice to make a handwritten note of the information so you can add to the system when you are able to.
If an entry is made retrospectively then it is helpful to document the source of the information, eg, 'entry typed from handwritten note'. In circumstances where it is not immediately obvious why a retrospective entry is necessary (such as on a home visit), it may also be helpful to include the reason why the entry wasn't made at the time.
A computer audit trail will always indicate when a patient's records were accessed and when any changes were made to those records. However, it is still important that if there is a significant delay in adding information, it's obvious to anyone reviewing the record where and when an entry has been made retrospectively.
A member contacted the MDU asking for help with a complaint made about the advice she gave to a patient during a consultation.
The member had reviewed the patient's medical records while drafting her response to the complaint. She was dismayed to find that although there was evidence that she had seen the patient on the day in question and prescribed some medication, she had not included details of the consultation.
The lack of a contemporaneous medical record meant that the member was entirely reliant on her partial recollection of the consultation, and couldn't provide full and evidenced explanation of her actions on that day in order to fully address the complaint.
The member explained that at times when she was particularly busy in surgery, she may leave adding the consultations to the records of patients until the end of the surgery to avoid running late. On this occasion, it appeared that unfortunately she had forgotten to go back and add details of the consultation to the patient's record.
The member was advised to explain to the patient why this consultation was not recorded in the records and apologise for this, and to explain that in responding to the patient's complaint she had relied on her memory of the consultation. The medico-legal adviser also recommended that she reflect on this incident and discuss it as a significant event at a practice meeting so that her colleagues could also learn from this. In her response to the complaint the member told the patient about the learning points her complaint had raised and explained what action she intended to take as a result.
In future she would change her practice so that as far as was possible, she would ensure that she completed adding the consultation to the patient's records before calling the next patient in, and if necessary make brief handwritten notes as a memory aid before recording this in the computerised records later. The member was also advised to update the record, making it clear that it was a retrospective addition based on her memory and why the record had not been recorded contemporaneously.