The Principles of Good Record Keeping in Healthcare Organisations

In today's rapidly evolving healthcare environment, safeguarding patient confidentiality is paramount for both NHS organisations and private medical bodies.

Clear and accurate record keeping is not just a requirement but a critical component of exceptional patient care. Inaccurate or poorly maintained records can lead to severe consequences, including compromised patient safety and legal repercussions. 

It is therefore imperative that healthcare institutions take immediate action to enhance their medical record-keeping practices, 

Let's discover how to assure good record keeping in your practice, safeguarding your organisation and delivering the best possible care for your patients.

10 Principles of Good Medical Record Keeping

To keep consistent records, here are the 10 principles that everyone on your team should live by.

1. Keep it Legible

You don’t have to write in cursive, but clear, legible handwriting is a must for good record keeping. Other professionals and the patient need to be able to understand their medical records and find the details they need at a glance. It is also important that notes are as accurate as possible – that means records being made during, or soon after a consultation, and that all records are dated.

2. Always Remember the Key Details

Remember to always double-check the patient’s name, date of birth and primary conditions against your records. In each interaction, notes should be made about who has made each decision, medications prescribed, treatments or procedures conducted, and your own details as note-taker (dated and signed). 

The General Medical Council recommends the following pieces of information be recorded as part of clinical records:

• Clinical findings

• Any decisions made & who is making the decisions

• Any actions agreed & who is making the decisions

• Any information given to the patient

• Any prescriptions or treatment

• Who made the record & when did they make the record

3. Avoid Abbreviations

While many medical terms have their own abbreviations, you should avoid any non-standard medical abbreviations on patient medical records. This can allow patient medical records to be misunderstood or misinterpreted. Always avoid shortening important information and list things concisely but clearly. 

Modern patient care is multidisciplinary, so there should be no room for ambiguity in patient medical records, as they can be passed across different departments and settings within a facility.

4. Sign and Date Every Further Comment or Addition

Medical records aren’t a one-and-done document. They will be added to and amended many times during a patient’s stay, and can become very confusing if not kept tidy. Remember to sign and date every new comment or piece of information, so you can look back and understand the timeline of treatment.

5. Remember to Record What The Patient Has Been Told

Medical records don’t just record treatments and prescriptions – it's also important to document conversations. Every time you discuss an update with your patient, make a note with the date, time, what has been discussed, and any decisions or questions the patient may have had at the time.

6. Remember That Documents Aren’t Always Paper-Based

Medical records are not exclusively paper documents. Doctors may take an audio or visual record of updates, or exchange digital communications with patients through email or text. Keep track of these meticulously and make a note of where they are stored so they can be accessed if needed.

7. Stick to Retention Periods

Most medical institutions have a policy of keeping written records for a certain period (usually up to a year), before moving them to a different format or disposing of them. Remember to keep records organised and on a rolling basis, make sure all old records are moved securely.

8. Move to Digital Records When The Time Comes

Having a robust digital system in place to store older records is crucial for modern medical institutions. You should be able to find records using a patient’s name and date of birth, and instantly see their previous details.

9. Always Take Action With Any Inaccuracies

Having an inaccuracy on a medical record is very serious. As soon as one is brought to your attention, follow the information listed by the NHS on correcting medical records. Do not delete or alter the records in any way before going through the due process.

10. Employ a Secure Shredding Service

At the end of the retention period or when a document is no longer needed, secure destruction of medical records, such as shredding, is a vital component of any healthcare organisation record keeping policy. 

To guarantee that your medical records stand up to changing industry regulations and GDPR, your medical institution should use a secure and efficient shredding service to ensure safe destruction of your confidential patient records & documents. 

Additionally, once legal retention periods have ended, partner with a confidential information disposal company, such as Shred-it, to maintain compliance and protect patient privacy.

Discover more about document retention in the healthcare sector at the NHS.

How We Can Help

Shred-it offers flexible paper shredding & document destruction services designed to meet your needs in a fast-changing medical landscape. From secure document shredding to hard drive  destruction, we provide comprehensive solutions to ensure the confidentiality of your information. 

Our services include on-site & off-site document and hard drive destruction and speciality shredding services, allowing you to choose the most suitable option for your data security requirements.