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Patient records: avoiding the pitfalls

It may sometimes feel tedious and time consuming, but keeping proper records could save your career and improve care standards. Solicitor Kate Hill explains

Writing 'let's get down and boogie' or scribbling a tribute to your favourite football club in the margin of patient notes may seem lighthearted and harmless and hardly a reason for reprimand. However, earlier this year, this eccentric approach to note keeping led to the physio in question being cautioned by the Health Professions Council.

In this particular case, the regulator judged that writing comments such as 'the Gunners are going to win' within patient notes was 'inappropriate conduct' in relation to record keeping, and that this 'impaired the fitness of the registrant'. The regulatory authority also noted that such behaviour contravened current standards of proficiency for physiotherapists.

A lackadaisical attitude to record keeping can be professionally destructive in other ways. For too many physios, the process of writing patient notes is seen as time consuming and a less important part of their role than actually treating patients. Consequently, very sparse notes are common. However if a physio is asked in court to explain the treatment of a patient they saw three years ago for two half-hour sessions, their notes are the only documents they have to go on. Without complete notes any physio will struggle to give a good account of themselves. In contrast the patient may claim to remember every single detail about their treatment and every word that was said. If patient recollection is the basis of a claim against a physiotherapist, and the physio lacks decent notes, the chances of providing a good defence are greatly reduced.

Usually litigation proceeds not because physios have done something wrong, but because they've not documented their actions and thought processes properly. Handling clinical negligence claims in England, a 2001 report by the National Audit Office, revealed sub-standard record keeping accounts for over 40 per cent of clinical negligence claims. The message is clear - want to have a go at a healthcare professional? Start in on their note taking.

So what can physios do to improve their documentation skills? While a list of the more technical requirements for good record keeping are to be found in standard 14 of the CSP's core standards of physiotherapy, there is currently very little other help out there for professionals who want to raise standards. The chances are that the only feedback practitioners are currently getting is limited to ink colour, legibility, date, time and clinical content. Training days are available but are expensive. Fortunately there are simple, practical ways in which physios and other healthcare professionals can ensure more precise documentation and better communication with patients. One technique involves introducing the concept of the 'five-minute appraisal' (FMA).

Here the accuracy of notes made and, the language that is used, are appraised. For example, consider the following three statements: 'Risks advised'; 'Patient slept well' and 'Patient reassured'. What is wrong with them? How could the author of the statements improve the entries? These comments are fairly common but provide no real information. The first fails to say what risks were mentioned. Were they of particular importance to the patient's circumstances? Was the patient concerned about any of the risks? Were alternatives discussed? The second fails to explain how this judgment was made. Was it made on the basis that the patient was in bed, was snoring, was not moving, was not crying out in pain? Was the patient asked if they slept well? It has been known for this comment to have been made in a patient's notes when in fact they have been dead for several hours.

The third fails to explain why the patient needed to be reassured in the first place, what the concerns were, what explanations were given and how the health professional knew that the patient was no longer anxious. The FMA also operates on the premise that physios and other healthcare professionals should be aware of why records need to be kept. As well as answering allegations of negligence, keeping good patient records is vitally important for the continuity of patient care, for clear communication between health professionals and teams, and for clinical audits and maintaining standards. With this in mind, the FMA works by equipping staff with better critiquing skills when assessing records. There are three key areas here. The first is differentiating between fact and opinion. Physios should apply the rule that wherever an opinion is expressed it should have a factual basis. This will better inform colleagues who come to treat someone after you, from a continuity point of view, and it will also help to demonstrate compliance with the legal standard of care. The statements mentioned above were nearly all opinions expressed without a factual basis.

The second core area is ensuring that tasks are completed. For example, the phrase 'patient reassured' only describes half the task. Did the patient actually feel any better after he had been reassured? Third, there is the need to ensure that the patient's medical record is accessible to a multidisciplinary team. This will cut down on communication errors. The final part of the appraisal method involves, once a week, staff inviting a peer to critique one entry they have made. It is far easier to criticise someone else's work. By limiting the appraisal to five minutes it is manageable, and by insisting on once a week it ensures learning is not lost.

A common physio complaint about note keeping is the length of time it takes. And this is where the use of patient information leaflets to improve standards of record keeping can prove particularly successful. Good information leaflets, when used properly, can help healthcare professionals to document more precisely without them spending a lot more time writing. Leaflets can also help to involve patients in their care and can provide evidence of discussions and information that has been given. Most health professionals will discuss the information that is contained in a patient information leaflet as a matter of course. However, having the leaflet allows you to detail a rather lengthy conversation by documenting in the patient's notes that you have discussed the information in the leaflet with them. Health professionals must take care though that any differences in information given to a patient to reflect their own personal circumstances should be documented in the patient's records. Patient information leaflets do more than just save health professionals' time.

Good patient information leaflets are also important as they can:

  • give patients confidence, so their overall experience as a patient is improved;
  • remind patients what you told them if, due to stress or unfamiliar language, they forget what they were told;
  • allow people to make informed decisions - it gives people time to go away, read the information and think about the issues involved;
  • help to make sure patients arrive on time and are properly prepared for procedures or operations; and,
  • involve patients and their carers in their treatment and condition.

Patient information leaflets should be fairly straightforward to produce and the initial time investment will save any team and department considerably more time in the future. But the leaflets are only useful if they are well produced and are kept up to date. It is essential for healthcare professionals to ensure the research and evidence on which the documents are based is robust and current. It is also a good idea to keep records of the production meetings that take place. Finally, it is vital to keep all back copies of patient information leaflets and number them. When they are referred to in patients' notes the number of the leaflet referred to should be documented. Then, if litigation occurs in two or three years, the exact information that was referred to can be found. Patient leaflets and the five-minute appraisal require time and commitment from healthcare professionals and a culture change regarding documentation. However, if properly used, both have the power to help healthcare professionals manage the time they spend on documentation more effectively and greatly improve standards.

Kate Hill is a solicitor in the healthcare department at Radcliffes Le Brasseur. She is also managing director of InPractice Training and provides regular legal training to physiotherapists.

How to write patient information leaflets

There are some guidelines physios should follow on how to create clear, helpful patient information leaflets.

  • Try to write from the patient's point of view and put yourself in the place of someone who may have little knowledge of what you are talking about
  • Use everyday language. Avoid jargon and acronyms, and use plain language to make it easier to read. As many as seven million people (roughly one in five adults) in England have difficulties with basic literacy and numeracy, but that does not mean you have to be patronising or use childish language
  • Use patient-friendly text. Use personal pronouns such as 'we' and 'you'. Do not use frightening language, for example, 'electrodes will be put on your chest'. If it is difficult to avoid using some medical terminology, such as 'nuclear medicine', give an explanation
  • Be relevant to individual patients
  • Information should be given in context with other information given to patients, for example, letters, leaflets and appointments.
  • Reinforce the messages that patients have been given at the clinic
  • Avoid instructions. If you are asking people not to do something, explain why they shouldn't do it
  • Help people make decisions by giving them information about facts risks and side effects as well as benefits
  • Cover only one treatment or condition per leaflet
  • Give details of where other information can be found
  • Information must be up to date so give the most recent practice and latest phone numbers
  • Let people know if the information is available in other formats, for example, on audiotape.

To make text more inviting to read, use the following:

  • Short sentences - in general no more than 15 to 20 words long
  • Lower-case letters, where possible, as they are easier to read
  • Consider a question and answer format, as this can divide up text
  • Alternatively, consider bulleted or numbered points
  • Try not to use long paragraphs - divide them up using headings and new paragraphs
  • Use white space to make the information easier to read
  • Consider using large bold fonts to emphasise text
  • Numbers from one to nine are easier to read if they are written in words, and numbers from 10 can be represented as numbers
  • Try to use a font size of no less than 12 point in word processed text.
  • Diagrams and pictures can be very effective - use them to illustrate text, remembering to label them. Try to avoid poor quality 'clip art'. It is better to visit www.nhscommslink.nhs.uk or use the NHS photo library at www.photolibrary.nhs.uk

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