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As a specialist healthcare solicitor with more than 20 years’ experience, I’ve supported and advised thousands of healthcare professionals and organisations across the UK and Asia ranging from regulatory defence (particularly General Medical Council matters), clinical negligence claims, inquests and, in the most serious cases, manslaughter cases. One theme comes up time and again is healthcare records. Over the years I have provided clients with bespoke training on improving standards, including healthcare records. Drawing on that experience and on the situations where things have gone wrong and prompted clients to seek my advice, I’ll be sharing a series of “top tips”. My current top tips focus is on healthcare records and why it is so important to get the approach right.

Top tip 1: Write it up promptly

Always prepare the record as soon as you can following the assessment or interaction. There is no mandatory time limit for making a record, but writing while events are fresh in your mind improves accuracy, especially when you are seeing multiple patients and other events intervene. Delay can affect the accuracy and reliability of a record and, crucially, inaccurate/incomplete records mean that the credibility of the maker of the record (you!) can be called into question should there be a complaint or claim for clinical negligence

Top tip 2: Assume the patient may read it

Be mindful that the patient (or their carers/relatives) may see the record. Avoid inflammatory or inappropriate comments that could be perceived as unfair by a patient. Always be prepared to have the record scrutinised and never include anything in the record which you cannot justify from a factual perspective.  If you are raising safeguarding concerns, it is essential that as much information is included as possible. Direct quotations can be particularly helpful, even if they include threats or swearing as the context is essential.

Top tip 3: Never amend the record when you receive a complaint

Never amend a record when you receive a complaint, claim or notice of an inquest. Retrospective amendments may occasionally be permitted (for example, if you spot a clear factual error such as the date), but it must be crystal clear on the face of the record itself what was amended, when and, importantly, why. It can lead to serious questions about motive, honesty, accuracy and your credibility…beware!

Top tip 4: Record the advice properly

Set out the advice that was provided, including specific advice on follow up/return, for example, what a patient must do if problems persist or deteriorate. This is often a problem area especially in progressive conditions such as cauda equina where I often see “advice given” or “red flags given”. Years ago, the term “SOS” (unfortunately!) often featured in records, with clients telling me they had “obviously” advised the patient to come back if help was needed. The problem is that none of the specifics are documented in the record, so the record is vague and unhelpful. Fortunately, “SOS” is used less now, but it still appears sometimes. Treatment and follow up advice must set out the context, the particular red flags advised and, importantly, what to do/who to contact.

Top tip 5: Pause and check before you save/move on

Review the record before you save/move on. I understand the pressure and demands of busy healthcare roles – I’ve advised many healthcare professionals over the years. However, healthcare records protect you in the event something goes wrong. If questions are raised months or years down the line, when you won’t realistically remember the specifics of an assessment/consultation then getting the records right at the time might save significant time and stress in the future.

The GMC’s Good Medical Practice (2024) is a useful reference point on record keeping from paragraph 69 onwards. Domain 3 Colleagues culture and safety – GMC

Get in touch

In the coming months, Lisa will be sharing more ‘top tips’ drawn from the issues she sees most often in practice, drawing on situations which have prompted healthcare professionals to seek legal advice. If there is a specific area that you would like Lisa to focus on in this series or if you would like to discuss record keeping, training and support or have an issue relating to the any of the above please contact Lisa at l.nabou@bmalaw.co.uk.

How BMA Law can help

BMA Law specialises in providing expert legal advice to healthcare professionals and organisations. Our team of specialist healthcare lawyers can support you with a wide range of matters, including GMC and CQC investigations, clinical negligence defence, inquests and Coroner’s Court representation, employment law, and disputes. We also provide bespoke training for healthcare providers on patient safety, legal compliance, and reducing litigation risk.

Please contact us on info@bmalaw.co.uk or 0300 123 2014 to discuss how we can assist you.