IF THE CORRECT PATIENT INFORMATION IS NOT RECORDED OR DOCUMENTED WHAT ARE THE CONSEQUENCES FOR THE HEALTH CARE PROFESSIONALS?
Implications for the professional
Poor record keeping by health care professionals could result in legal action being taken against them, which may lead to severe personal and professional consequences.
It is important to recognise that healthcare professionals are accountable for their actions, and omissions, in a variety of ways. If they are ever called to account for their actions/omissions, relevant documentation can be used as evidence which may either corroborate or disprove the allegation.
When health care records are brought before a court of law, the professional documentation will craft the first impression that the judge will have of the individual in question, it is vital that the documentation reflects professionalism. Negative factors include scruffy handwriting, overuse of correction fluid, deletions that leave original entries obscured and inappropriate comments.
Take a look at the video below of the General Practitioners experience where there was insufficient information in the patient notes:
Healthcare professionals are accountable for both their actions and their omissions in record keeping.
- Poor record keeping can have drastic consequences for the person receiving care
- Healthcare professionals are not only accountable to their employer and professional body, but may also be held legally accountable for their actions
- Any resident’s medical record can be brought before a court of law as evidence during a trial
Smith & Parkhouse (2017)
Bridget Dimond a Barrister-at-Law, Emeritus Professor describes hearings where health care records may be used as evidence, and explores the key points associated with the legal status of healthcare documentation in the UK.
Hearings in which records may be used include the below:
- Civil court hearings
- Criminal court hearings
- Disciplinary hearings
- Fitness to practice hearings
- Complaints investigations including independent review by the Healthcare Commission and referral to the Health Service Commissioner
- Secretary of State inquiries
- Police investigations (in accordance with the procedure under the Police and Criminal Evidence Act 1984)
- Coroners’ inquests
- Employment tribunals
Key Points from a legal perspective:
- Any document or other evidence can be required to be produced in court if it is relevant to an issue arising in the case.
- Such information is usually seen as hearsay evidence, i.e. it does not in itself prove the truth of what is written.
- Those who wrote the records will usually be required to give evidence in court to substantiate what was written.
- Two major exceptions to the power of the court to order disclosure of records are: the right to withhold disclosure in the public interest; and legal professional privilege.
To conclude health care professionals have a shared responsibility to ensure that the correct process and legislation is followed when recording information and documentation for patients. The outcome of poor record keeping can lead to detrimental results for both resident and health care professional. To ensure high quality patient care, clear, accurate and appropriate documentation is essential.