MDU warns GPs to keep electronic records ‘clean’

 The Medical Defence Union has warned GPs that if they do not scrupulously maintain their electronic patient records they may be left unable to defend negligence claims.

An article published in the MDU Journal warned that both existing electronic patient records systems and the NHS Care Records Service contain pitfalls for GPs, and that omissions or non-standard entries in the clinical codes could place clinicians at a disadvantage should they have to legally justify their actions.

One example given by Dr Frances Szekely, senior medical claims handler at the MDU, based on claims handled by the organisation, is that a code such as the one for "brain tumour" could be entered on a patient record, with the free text qualification of "not found".

Dr Szekely argues that this is a dangerous thing to do, because the record could be interpreted as saying that the patient presented with the condition. Should the GP be taken to court, this also leaves the practitioner open to accusations of record tampering or lack of understanding of the system. Furthermore, data searches of the records may only pick up the code without the free text qualification.

Another problem with record-keeping stems from practices that do not create new login identities for locums, leaving GPs who were away at the time responsible for any mistakes they make.

"The MDU is notified of numerous claims where a doctor may have a vague memory that they were on a course or off sick during a certain period," explained Dr Szekely. "Yet because the records appear to suggest that they conducted the recorded consultation – and without hard evidence to the contrary – they may have to assume liability for these consultations."

Dr Szekely also points out that many electronic records do not have the capacity for items such as diagrams, illustrations or other annotations, making them less flexible than paper.

Dr Szekely said: "Keeping detailed records has always been a cornerstone of good practice and this continues to be true, even in a digital age."

"Going paperless, without having ensured that all staff have the skills and training to enter the same level of detailed clinical information onto their computer system as they would have when using paper records, may place practitioners at a disadvantage when providing care," she added.

The MDU recommends that practices make a "formal review" of how electronic record systems are used and make sure that both clinical and non-clinical staff are fully trained in the use of the system. It also stresses that every practice should appoint a Caldicott Guardian to champion data security, accuracy and legal compliance.

"Computerised records, like Lloyd George cards, will only ever be as good as the information that is put onto them," said Dr Szekely.