NHS England » High quality patient records

Everyone in a health and care organisation is responsible for managing records appropriately. It is important, therefore, that all general practice staff understand their responsibilities for creating, maintaining, and disposing of records appropriately.

The Records Management Code of Practice

The Records Management Code of Practice provides a framework for consistent and effective records management, based on established standards.

The Code provides detailed advice including on:

What a record is – in primary care this includes patient records. It also includes administrative and business records such as finance, personnel, estates and practice websites. Records can be held in a variety of formats including paper, digital, emails, X-rays or photographs.
Legal and ethical requirements – all health and care professionals must manage records in accordance with the law. This includes keeping accurate records and only keeping records for as long as necessary. Staff who are registered to a professional body, such as the General Medical Council (GMC) will also need to follow their guidance. The Caldicott principles also need to be complied with.
How to keep and store records – this includes the management of both digital and paper records.
How long to keep records – recommended minimum retention periods for different types of records are set out in the Code. There is also a searchable table where you can look for the minimum retention period for different types of records. You can, for example, search ‘GP’ to find the retention period for GP records (which is continual for a living patient, for example), or ‘building’ to find out how long to keep records relating to building works.
Action required when the minimum retention period is reached – some records can be destroyed, whereas other records will need to be permanently preserved.

National guidance has been produced in summary form for health and care professionals and this summarises the actions all health and care professionals should take.

Designated record leads

Your organisation should have a designated member of staff of appropriate seniority who leads on records management (this is likely to be the practice manager). The practice should have approved records management policies and procedures.

High-quality patient records are the foundation of good clinical care delivery. Delivering safe and efficient patient care depends on having high quality patient records and, therefore, the right information available when clinical decisions are made. New models of care delivery mean that records are of high quality and that they are also fit for sharing.

High quality records

High-quality electronic records contain all the information needed about a patient’s health to provide good care to that person. This information can be relied upon to make clinical decisions with confidence when it:

is accurate
is appropriately and correctly coded
has the correct context

contains no inaccurate or data not related to the patient

is curated to allow all this information to be accessible

Missing, inaccurate, or non-standard information can, however, lead to Inconsistent care, or risk the quality, and safety, of care delivered.

It is important to remember that most health professionals are not data experts and that the link between poor data quality and its effects on patient care are not always easily appreciated. This is especially true as the purpose becomes more distant from direct care, the original purpose for which most information is collected in a GP patient record. In research and population health management, for example, care needs to be taken interpreting this information as the data may not have been originally collected for that purpose.

This guidance is aimed at helping to understand the importance of record quality.

What is a high-quality record?

This guidance focuses on records which are primarily composed during the direct care of the patient. Non-clinical purposes and secondary uses in modern general practice systems are almost completely dependent on the quality of the data captured as part of direct care. Most of this data is captured by health care professionals interacting with their GP IT system.

The representation of health data is complex, but it needs to fulfil the purpose for which it is being considered. Understanding the various purposes of health records can help define what a high-quality health record consists of. It is, however, important to remember that the primary purpose of the record is to support the individual care of the patient. It is unlikely that a record will fulfil all purposes equally, and often there is a trade-off to be considered.

Defining record quality

The meaning of what previously may have been described as a high-quality record has changed dramatically over the years. It is also important to remember that patient record systems contain a variety of clinical and non-clinical data from demographics, administrative, correspondence, clinical interactions, etc. It must also go further to capture context and in a modern-day general practice IT system, providing a conduit by which health professionals can communicate, interact, and record decisions. The quality of the record must be defined in the context for which it is used.

The record must also be in a format that facilitates the sharing of information across organisational boundaries. The ability to share patient information from the health record is becoming an ever-increasing demand on the GP health records generally.

A high-quality record, therefore, needs to:

be complete, accurate, relevant, accessible, and timely (CARAT)
enable the effective and reliable presentation of patient information from the patient’s records relating not just to the clinical data but other forms of data such as demographics, appointments, administrative, documentation, etc.
allow the data to be arranged in the record to support the purpose for which it is being used. To achieve this there is a complex relationship between how the data is structured, described, and coded (typically using SNOMED CT). It is important to understand the capabilities of the system in order allow data to be entered to support this aspect of record quality. This is critical to research and other secondary purposes
capture information relating to a consultation which can be in the form of highly descriptive narrative content and context, or highly structured clinical data in the form of a clinical vocabulary such as the SNOMED CT
allow the recording and automation of clinical and non-clinical data entry through tools designed to facilitate this such as templates, concepts, protocols etc.
be in a format that allows IT systems across the health and care sector to communicate with each other. (This is beyond the scope of this guidance but organisations such as the Professional Records Standards Body provide standards to improve data quality and interoperability for precisely this purpose. It is important that the data is of the correct format, abides by the standards and is of sufficient quality to facilitate this purpose)

Assessing and ensuring record quality

Clinical data quality has multiple dimensions and ultimately the data needs to be fit for purpose. The Government Data Quality Hub has extensive guidelines on how data quality is assessed. There are other definitions, but Annex A to this article has a more complete overview and outline of the dimensions of data quality with respect to patient records.

From a more practical perspective, ensuring record quality in current GP IT systems can be achieved by:

always checking you are entering information into the correct patient record
entering information into the patient record in as to close real-time as possible or as soon as possible after the interaction has taken place, which improves accuracy and timeliness and reflects professional guidance
using coding strategies that promote record quality and consistency, e.g. through the use of standard coding such as SNOMED CT, and templates that can draw details from the patient record and allow other information to be entered and automatically coded (coding ensures consistency across the practice and other care settings, reduces errors, increases speed of complex data entry, and further facilitates effective indirect and secondary uses)
understanding the capabilities of the GP system and becoming more familiar with the local templates for data entry and service delivery
ensuring the record is an accurate reflection of the facts and does not contain irrelevant or superfluous patient information or contain acronyms that are not expanded, which is especially important when patients are increasingly having access to their health records

How coding improves a record entry

Whilst coding can increase the machine-readable element of a record, free text can provide detailed narrative content and context that cannot be captured using coded entries alone. High quality records are often a mixture of free text (which contain complex narrative and easily human readable) and coded data.

Encounter-based record

Encounter-based GP records typically contain information relating to a single episode or encounter relating to:

problem or diagnosis | which can be any condition, symptom, sign, investigation, or diagnosis that is relevant and active to that encounter
presenting complaint | the primary reason for the attendance related to the encounter or problem

They can also contain a multitude of other information including but not limited to:

symptoms | subjective description of the experience perceived by the patient
signs | objective evidence of abnormal finding relating to symptom or problem
investigation results | radiological or laboratory finding
suspected diagnosis | a possible diagnosis which may or may not require further investigation
plan/comment | a descriptive narrative of the next steps including any safety netting described to the patient

An encounters problem can be defined in many ways and varies from system to system.

Problem orientation

The above encounter-based record needs to be linked to a problem and, in turn, a problems list which persists between encounters.

Problem orientation consists primarily of:

problem list | is a summary of the patient’s problems categorised as active/inactive.
problem title | ideally a SNOMED CT coded item that summarises the problem
active problems | what is the active health problem requiring current healthcare input or awareness
inactive problems | previous problems suffered by the patient that do not require any current healthcare input

The problem itself is typically defined as a recognised SNOMED code. This can be accompanied by variety of attributes such as episode descriptors (First Episode, Review, Flare up, etc) significance, active, duration.

Different system suppliers use these attributes differently, so it is important to ensure you understand how these can be utilised. Often, however, some of these attributes don’t have well-defined states, for example major/minor significance of problems are not clearly defined and need to be considered in the context of the problem itself.

Problem lists

General practice records are primarily problem-orientated and encounter-based, but when there is a sequence of encounters, the GP record can become a powerful longitudinal clinical record of a particular problem. All these problems form the problem list. How well this clinical information is maintained and organised will vary from practice to practice and clinician to clinician. The problem list can provide a powerful summary of a patient’s past and present conditions that may be relevant to their care or that particular encounter.

The way problem lists are displayed and managed also vary, based on the clinical system, and it’s important to become familiar with this functionality. Current clinical systems also have several other features that enhance the problem list by allowing users to navigate to any documents, medications, or referrals, linked to a particular problem or SNOMED CT code.

The key to a high-quality problem list is that it encompasses all those aspects of data quality outlined in Annex A (namely that it is complete, accurate, relevant, accessible, and timely). This will involve an element of curation from the clinical staff maintaining the problem list.

Most system providers have several methods to maintain the quality of the problem list. These include changing the status/descriptor of a problem, ending a problem, grouping problems, combining problems, evolving problems, deleting problems.

Some examples of the evolution and development of a problem list over time can be found in the PRSB and Royal College of Physicians (RCP) Guidance for recording problems and diagnoses in electronic health records.

There are more advanced aspects of problem-orientated records management, including linking documentation or entities such as documents, referrals, and medication to problems. Other facilities include categorising problems by significance, length of problem activity, priority. Some systems can even nest, merge, and cluster problems. These advanced features can aid and improve record quality but do vary based on GP system supplier, so please contact your supplier for further details.

Amending patient records for quality

Records should not be amended except in one of a few circumstances, for example when:

the patient has challenged content, and the challenge is considered appropriate
information about another patient has been entered in error
the information is incorrect

If record content is incorrect then it should be corrected. Modern health record systems allow deletion or amendment of the content whilst keeping a clear audit trail of what has been amended. It is also good practice, and most GP IT systems allow for, a free text note of the reasons for the amendment or deletion, with the date and time of the change. Correcting a record helps improve its quality.

Clinical patient data is considered special category data under the UK General Data Protection Regulations (GDPR) and Data Protection Act 2018. This dictates that patients should be allowed the right to rectification of inaccurate personal data without undue delay.

Consulting without a patient record

There may be occasions when a patient’s record is not available, for example:

in an out-of-hours visit (where the patient record is unavailable, or patient has opted out of record sharing)
if the patient is a temporary resident
if the IT system is unavailable for some reason

A full set of notes should be taken, including any discussion of history, medications, etc., and added to the full record at the earliest opportunity. A note of the reasons for the record not being available should be included. The record should be coded appropriately when access is available to the GP IT system.

Other helpful resources

Medical Defence Union, Good record keeping
Medical Protection Society, Essential guide to medical records
Medical Defence Union, Consulting without notes
University of Nottingham, PRIMIS

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