Professional Record Keeping

Healthcare professionals should maintain records of the patient care activities that they perform. It is recognised that good record keeping supports patient safety, evidence-based healthcare, continuity of care, and good professional practice. Record keeping also facilitates audit and quality monitoring, which has become of increasing significance in many healthcare economies, and is also important from a medicolegal perspective.

There are three important concepts in law concerning the generation and subsequent use of records of patient care and professional activity.

They are:

• Confidentiality

• Consent

• Liability

These three concepts underpin the need to record medical observations and patient care interventions.

Confidentiality

The privacy

Health professionals therefore are said to have a duty of confidentiality, and are required to ensure that the confidentiality of patient information is safeguarded.

Where there is a need to transfer patient information from one care provider to another, professionals should ensure that the transfer of information takes place as securely as possible, in accordance with current NHS information governance requirements. When deciding whether or not to share patient information, the pharmacy professional’s duty of confidence should be weighed against the need for the continuity of effective patient care, and the possible consequences to the patient if the information is not shared, so that a decision is made that is in the patient’s best interest.

There are some clearly defined circumstances where a pharmacy professional is required to share patient information with a third party without the patient’s consent, for example to assist the police in the investigation, detection or prosecution of serious crime.

However, for any pharmacy service other than the dispensing of medicines, which requires an activity record containing patient identifiable information, patient consent must be sought to record and store their personal data. Liability

Records of patient care and treatment have traditionally played a major part in providing evidence of appropriate patient care in situations when allegations of negligence are made. This has not been a major issue for pharmacists in the past, but as pharmacists take on new roles, and provide clinically-focused professional services, they will need to make appropriate documentation of patient care interventions in order to account for their professional decision making.

Some pharmacists may be reluctant to document professional activity in case it is challenged by a patient or relative at a later time. However, pharmacists should bear in mind that there is an equal liability associated with not comprehensively recording details of care provided and a contemporaneous note is often invaluable at a later date in helping to demonstrate that the appropriate standard of care was provided by the practitioner