Investigation underlines need for accurate medical records

medicalfiles

A recent investigation into record-keeping at a large NHS trust highlights the importance of having adequate safe custody measures in place, Bupa Health Clinic’s Graham Johnson says.

The recent announcement of the outcome of the investigation by the Care Quality Commission (CQC) into Colchester NHS Trust and allegations that medical records of people’s treatments and appointments had been changed should remind us all of the importance of accurate record-keeping, and what data we can retain or share and with whom.

Concerns over record-keeping are nothing new, and it is noticeable that allegations concerning nurses’ record-keeping are often highlighted in hearings brought before the Nursing and Midwifery Council (NMC). An integral part of an occupational health (OH) clinician’s role is to record clinical history and to ensure that this accurately reflects what the person said. When carrying out health surveillance, this and any observations that result from the assessment performed are then reported to the employee and the employer. The outcome of these assessments should be restricted to a statement on the employee’s fitness to continue in their role or to consider a temporary restriction – for example, that the employee should no longer be working with vibrating power tools.

The information should be limited to these types, although from my experience of teaching Health and Safety Executive (HSE) inspectors reports have been known to include the hand-arm vibration syndrome Stockholm staging scale in the health surveillance result. This can be done only with the employee’s consent as it is sensitive personal information.

Safeguarding patient data

The overarching premise for the safe custody of clinical records is contained within the Data Protection Act 1998. The need for justification for the retention of sensitive medical information has been highlighted by the Information Commissioner’s Office (ICO) in relation to drug and alcohol testing. The code of practice (ICO, 2011) states that drug and alcohol testing is unlikely to be justified unless this is carried out for health and safety reasons. Any recording and retention of the result of drug and alcohol testing by the OH service is likely to be viewed as a breach of the Data Protection Act.

The "Code of professional conduct" (NMC, 2002) advises that good note taking is a vital tool of communication between nurses. It states: “[Nurses] must ensure that the record for the client is an accurate account of treatment, care planning and delivery. It should be written with the involvement of the client wherever practicable and completed as soon as possible after an event has occurred. Contemporaneous notes should provide clear evidence of the care planned and delivered, decisions made and the information shared. Records should be completed as soon as possible after an event has occurred and they must not be tampered with in any way.” Entries made in paper records should be clear, legible, signed, dated, timed and clearly attributable to the nurse who made them.

Publication of guidance from the General Medical Council (GMC) on confidentiality when disclosing information for insurance, employment and similar purposes (GMC, 2009) led the Faculty of Occupational Medicine (2010) to publish revised guidance, which instructs that a doctor should “offer to show your patient, or give them a copy of, any report you write about them for employment or insurance purposes before it is sent” unless:

  • they have already indicated that they do not wish to see it;
  • disclosure would be likely to cause serious harm to the patient or anyone else; or
  • disclosure would be likely to reveal information about another person who does not consent.

While the NMC has chosen not to issue similar guidance, it is seen by most OH nursing professionals as good practice to follow the same process as their clinical colleagues.

The health record and keeping employees well

Non-clinical health records produced as the result of statutory health surveillance are vital in supporting the maintenance of an employee’s health and wellbeing, as is the sharing of information with the employer. The health record is integral to this objective. Various regulations require that records be retained for at least 40 years from the date of the last entry.

The HSE recommends that the health record should include details about employees and the health surveillance procedures relating to them, and should include a worker’s: surname; forename(s); gender; date of birth; permanent address including postcode; national insurance number; and date their present employment started. The recorded details of each health surveillance check should also include the date it was carried out and by whom, and the outcome of the test or check (HSE, 2013).

Vigilance is required to maintain high standards in record-keeping, and as healthcare professionals are subject to increasing scrutiny regarding their record-keeping the need for sound clinical governance in this area is of paramount importance if we are to retain employee and employer trust.

References

Information Commissioner’s Office (2011). "The employment practices code".

Nursing and Midwifery Council (2002). "Code of professional conduct".

General Medical Council (2009). "Confidentiality".

Faculty of Occupational Medicine (2010). "Guidance on ethics for occupational physicians".

Health and Safety Executive (2013). Health surveillance.

Graham Johnson

About Graham Johnson

Graham Johnson is clinical lead - nursing, at Bupa Health Clinics
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