Medical Record Keeping and Audit

Medical Records

Good organisation of medical records, whether electronic or handwritten, is essential for effective provision of services in orthopaedics and trauma. Surgeons are responsible for maintaining accurate, comprehensive, legible and contemporaneous records are maintained after all interactions with patients. The principal reason for maintaining medical records is to ensure continuity of care for the patient. 
However, good medical records are also essential in managing complaints and in defending medical negligence claims.

The GMC Good Medical Practice Standards outline keys aspects of medical record keeping and a clinicians responsibilities^1,2 :

• Be fully versed in the use of the electronic health record system used in your organisation and record clinical information in a way that can be shared with colleagues and patients and reused safely in an electronic environment
• Take part in the mandatory training on information governance offered by your organisation, including training on data protection and access to health records.
• Ensure that all medical records are accurate, clear, legible, comprehensive and contemporaneous and have the patient’s identification details on them.
• Ensure that when members of the surgical team make casenote entries these are legibly signed and show the date, and, in cases where the clinical condition is changing, the correct time.
• Ensure that a record is made of the name of the most senior surgeon seeing the patient at each postoperative visit.
• Ensure that a record is made by a member of the surgical team of important events and communications with the patient or supporter (for example, prognosis or potential complication). Any change in the treatment plan should be recorded.
• Ensure that there are clear (preferably typed) operative notes for every procedure. The notes should accompany the patient into recovery and to the ward and should give sufficient detail to enable continuity of care by another doctor. The notes should include:
  • Date and time
  • Elective/emergency procedure
  • Names of the operating surgeon and assistant
  • Name of the theatre anaesthetist
  • Type of anaesthesia performed and use of antibiotics/tranexamic acid
  • Operative procedure carried out
  • Incision
  • Operative diagnosis/findings
  • Any problems/complications
  • Any extra procedure performed and the reason why it was performed
  • Details of tissue removed, added or altered
  • Identification of any prosthesis used, including the serial numbers of prosthesis and other implanted materials
  • Details of closure technique
  • Anticipated blood loss
  • Antibiotic prophylaxis (where applicable)
  • DVT prophylaxis (where applicable)
  • Detailed postoperative care instructions including weight bearing status
  • Signature
• Ensure that sufficiently detailed follow-up notes and discharge summaries are completed to allow another doctor to assess the care of the patient at any time
• Ensure that you are familiar and fully compliant with the guidelines of the Data Protection Act 1998 around the use and storage of all patient identifiable information.

Inpatient Records

Inpatient records should be timed, dated and annotated with the details of the health professional making the entry.  Where medical records are handwritten, they should be clear and legible.

The significant details of every contact with the patient should be recorded to include:

• relevant clinical findings
• decision made/actions agreed (together with who has made these decisions)
• the information provided to the patient

Outpatient Records/Letters

There should be a communication between the Orthopaedic Department and the
patient’s General Practitioner following every outpatient attendance or inpatient stay.
Many NHS Trusts now copy outpatient letters to patients so that they are able to reflect on the record of the consultation after the event, and, if necessary, discuss any proposed investigations or interventions with their family or GP; this is good practice.

It is particularly useful in surgical practice if a letter from the outpatient clinic contains:

• a clear indication of the diagnosis
• a clear outline of the proposed investigation or treatment
• a clear outline of the potential risks or benefits of any proposed treatments

A review of the letter should give any clinician at a later stage an understanding of the thought processes that have gone into making the decision for that investigation or treatment. There should also be a clear outline of how the risks/benefit analysis has been conducted and concluded.

Ideally, the letter should be received by or available to the GP within 48 – 72 hours of the appointment.

Discharge Summary

Following an inpatient stay in hospital the GP should expect to receive a clear letter indicating diagnosis, investigations, treatment, future plans and follow up arrangements. The GP should be in receipt of that letter within three days of the patient’s discharge from hospital.

Operation Notes

There should be legible operation notes (typed if possible) for every operative procedure. The notes should accompany patients into recovery and to the ward and should be in sufficient detail to enable continuity of care by another Doctor. The operation note should include the details outlined in a previous part of this section, as recommended by the GMC. The operation notes should be sufficiently detailed to allow another Doctor to assess the care of the patient at any time.

Audit

Clinical audit is an essential component within a consultant orthopaedic surgeon's practice. 

The BOA produce standards of care that are useful for the surgeon to evaluate practice. Other subspecialty organisations will also produce guidance.

Surgeons should be given adequate time within their job plan and appropriate administrative support to allow for effective audit activity.

For consultants in management roles, establishing robust systems aligned with local, national, and international standards for audits work is imperative. 
 

References / Further Reading :

^{1.    Good Medical Practice 2024 . GMC.  https://www.gmc-uk.org/professional-standards/professional-standards-for-doctors
2.    Good Surgical Practice : A Guide to Good Practice. The Royal College of Surgeons of England. https://www.rcseng.ac.uk/standards-and-research/gsp/}