Step 1 – IDENTIFY THE PROBLEM(S)

Briefly state the Scenario: How do you balance time taken for patient care with record keeping? What is the minimum information you should record?

List the Issues that arise from the scenario

• Some healthcare practitioners complain about the time taken to complete medical records, especially electronic medical records. If excessive, this can detract from clinical care.

• Balancing patient care with record-keeping to provide high-quality care.

• Balance to collect as much clinical/organisational information as possible during emergency situations vs clinical time involved

Identify Critical Information required and Assumptions to be made

• What is defined as sufficient clinical records?

• What should be included in patients’ records?

• What are the requirements for information to support the organisation and management of healthcare?

• Data protection in healthcare

Step 2 – ANALYSE

Patient: Accurate record-keeping is essential to ensure that all healthcare professionals involved in a patient’s care are fully informed about their health status, facilitating a more holistic approach to treatment. This enables the delivery of good quality of care, in line with the principles of beneficence and non-maleficence. By maintaining detailed records, medical personnel can coordinate effectively, ensuring that each decision made respects the patient’s autonomy and aligns with their treatment preferences. Additionally, patient confidentiality must be upheld, as medical records are legally protected to safeguard sensitive information and ensure privacy. - UK General Medical Council. ‘Managing and protecting personal information’. At: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/confidentiality/managing-and-protecting-personal-information

Clinical: The clinical aspects of record-keeping involve the accurate and thorough documentation of all elements of patient care; assessments, diagnoses, treatments, outcomes, and decisions. Proper record-keeping ensures high-quality care, continuity, and effective communication among healthcare providers; they allow for clinical decision-making, patient safety, and optimal treatment outcomes.

Detailed records allow clinicians to identify potential errors or gaps in care. By reviewing past documentation, we can catch mistakes before they lead to harm, supporting proactive risk management.

Focusing on the most critical elements - vital signs, changes in condition, diagnoses, treatment plans, and medication orders - ensures that patient safety is maintained, and clinical decisions are based on accurate, up-to-date information. - ICRC. ‘Healthcare in danger: The Responsibilities of Healthcare Personnel working in Armed Conflict and Other Emergencies.’ 2020. At: https://healthcareindanger.org/wp-content/uploads/2015/09/icrc-002-4104-the-responsibilities-health-care-personnel.pdf

Legal: Healthcare providers have a legal obligation to deliver care that meets established standards, and accurate record-keeping is essential for demonstrating that this duty has been fulfilled. By documenting the care provided, as well as the clinical decisions made, records serve as evidence that the healthcare provider acted in accordance with best practices.

In the UK, the NHS Code of Practice and the General Medical Council (GMC) guidelines provide clear directives on how medical records should be kept and maintained. Proper documentation can serve as a defence for healthcare providers in the event of legal claims, proving that appropriate care was given. Failure to maintain accurate records can result in legal consequences, including liability for negligence or malpractice. - NHS Records Management Code of Practice, 2023. https://transform.england.nhs.uk/information-governance/guidance/records-management-code/records-management-code-of-practice/

UK General Medical Council. ‘Duties of a Doctor. Domain 1 Knowledge, Skills and Performance’. At:

https://www.gmc-uk.org/professional-standards/the-professional-standards/good-medical-practice/domain-1-knowledge--skills-and-development

The Geneva Conventions don’t address the issue of record-keeping, as this requirement applies both in military and civilian practice.

Societal/Military: Good medical record-keeping allows military medical units to manage resources efficiently by tracking the health status of personnel, the treatments they have received, and the medical supplies used. This can help optimise the allocation of medical personnel and equipment, ensuring they are deployed where they are most needed on the battlefield or during operations. They provide valuable insights into a soldier's physical condition, which is essential for assessing fitness for duty.

Additionally, accurate documentation contributes to military medical research, helping to improve care protocols and treatment outcomes. It creates trust between service members and healthcare providers, as personnel know their health data is being carefully managed.

Step 3 – FUSE

● Summarise conclusions

● Insert citations to key reference sources for your analysis

● Determine the exact Decision(s) to be made

While documentation is important for continuity of care, compliance, and legal reasons, the quality of patient care should always be the priority. When time constraints are a factor, clinicians should ensure that the most crucial information is recorded, and less urgent tasks (like detailed narrative notes) may be addressed during less busy periods.

Proper documentation is not only a professional and ethical obligation but also plays a crucial role in protecting both healthcare providers and patients legally. Well-maintained records provide vital evidence of the care provided, safeguard against potential claims of negligence, and ensure that patient safety and care quality are not compromised. - ICRC. ‘Healthcare in danger: The Responsibilities of Healthcare Personnel working in Armed Conflict and Other Emergencies.’ 2020. At: https://healthcareindanger.org/wp-content/uploads/2015/09/icrc-002-4104-the-responsibilities-health-care-personnel.pdf

Step 4 – DECIDE

• What is your Decision?

• Why (can you justify it)?

• Residual uncertainly, need for review?

Allocate specific periods during the day for record-keeping and patient care. For instance, short breaks between patient consultations can be used to complete or update patient records.

Training in efficient documentation techniques can help clinicians become more comfortable and quicker with record-keeping. Teaching staff to document only necessary and accurate information can reduce redundant or excessive entries.

Balancing patient care with record-keeping requires thoughtful time management, efficient tools, and prioritisation. By using technology, delegating tasks, and streamlining documentation processes, healthcare providers can maintain high standards of care while ensuring that necessary records are accurately kept.

Ultimately, the goal is to reduce the burden of documentation without compromising patient safety or care quality.

Reviewed and formatted by:

Adriana Salas Yeguez, MBBS Year 3 King’s College London

December 2024

Duties of a Doctor. Domain 1 Knowledge, Skills and Performance. UK General Medical Council. At: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice/domain-1---knowledge-skills-and-performance#paragraph-19 accessed 29 May 20.

Managing and protecting personal information. UK General Medical Council. At: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/confidentiality/managing-and-protecting-personal-information accessed 29 May 20.