It’s probably fair to say that anyone who has professional dealings with patients, service users, clients or their families will also know that records of care are integral to the interactions that healthcare professionals have with those they treat or care for.

From handwritten Lloyd George Cards, at times looking like well-practiced calligraphy, through to present day electronic case management systems, the accuracy, literacy and legibility of healthcare record has always been contingent upon clinician input. However despite, or in spite of, needing to be more IT literate this does not appear to have removed the potential for inaccuracy, incompleteness or being poorly written. Moreover it appears to have created issues peculiar to electronic records.

On the face of it, it isn’t a difficult concept to understand. A healthcare interaction of some sort will take place, whether it be a one off episode or one of a series of interactions, and that interaction should be recorded in near time and in a way that others coming after can understand what took place. Well that’s the theory anyway.

As a Nurse Analyst I am frequently frustrated (and at times shocked) by the poor standard of some healthcare records, where the net result can be ambiguity, or at times confusion, as to what was understood, done, said or agreed. The reality is that record keeping has become a much more complex, complicated and fractured process and this presents its own challenges for those reading healthcare records sometime after the event. Without exception all of the major healthcare professional bodies have standards, guidance and codes which refer to the accuracy of healthcare records and standards for documentation and record keeping (NMC 2015; GMC 2013; GDC 2013; HCPC 2016).

With this in mind we need to try and understand what makes records of care incomplete, inaccurate or poorly written and the impact this has.

I’ve concluded over the years that the typology of issues frequently seen within healthcare records can be classified under four headings:

I. Legibility with a clearly identified clinician including title/designation.
With regards to handwritten notes, I’ve noticed over the past few years that they increasingly start with the grade of the clinician e.g. F1 Doctor, ST2, ST7. That might mean something useful if the signature/name is legible but often it is not. On very few occasions there is the use of a personal stamp with name/designation and professional body number which makes it completely clear who the clinician is. Having taught on nursing degree top up courses in Singapore and Malaysia the use of personal stamps was wide spread, if not mandatory, in most hospital settings.

II. Poor grammar and absent or inconsistent punctuation
Being unable to ascertain whether the author of the notes is writing in the 1st or 3rd person; whether the description of events are those observed by the clinician or are those described by the patient; whether they are referring to events that have happened or events yet to happen can all cause significant problems. Verbatim transcribing of poor or absent punctuation/grammar and inaccurate words is actually very time-consuming since the natural tendency is to write it correctly, but of course when transcribing verbatim it defeats the object if any of that is changed.

III. Basic literacy
It is not uncommon for healthcare records to have errors in relation to:
• Use of apostrophe
• Incorrect word choice that will not show up on spell check i.e. where/wear; there/their/ they’re; to/too
• Inaccurate verb endings
• Colloquial use of English or where regional accent comes through resulting in errors that include:
o Is rather than his
o As rather than has
o Were rather than where or wear rather than were
o Nowt rather than nought
This is separate from simple keyboard errors where letters within words are transposed or missing. It is also worth noting that the majority of registered health professionals are degree qualified.

IV. The use of “Cut and Paste”
It is not uncommon to find extraneous and inaccurate content in healthcare records. This can include the details of other patients/service users in error, content that does not relate to the patient/service user or descriptions of events that either did not happen or could not have happened. In 2018 the House of Commons Work and Pensions Committee published the response to their call for evidence from Claimants undergoing assessment for the Personal Independence Payments or Employment Support Allowance benefits. The report described assessments being undertaken from template documents and assessments being completed under pressure of time. (House of Commons 2018)

And so, having said all of that, where does that leave us when we are trying to make sense of illegible, incomplete or poorly written records?

One strategy that I rely on is records of communication e.g. hospital letters back to the GP, letters between one specialist and another or letters to the patient/service user summarising events. However the inherent problem with this strategy is that it does not allow for the nuanced communication that might have taken place during the consultation. Another is to see if hospital letters were copied to the patient and which address it was sent to.

Discharge summaries can be helpful but invariably they are designed only to be a summary of events and if the issue is omissions of care then they may not help much. It’s also worth noting that the discharge summary may also have been put together by a (very) junior doctor e.g. F1/ F2, often relying on electronic notes which are cut and pasted into the summary, possibly compounding inaccuracies.

My experience is that, more often than not, a good quality chronology and related memo relies on a triangulation of sources with one source cross referencing and validating the other. It is time consuming but it is this attention to detail that makes the difference.

Ms Gez Bevan
RGN, BA (Hons) PGCE, MSc

Further reading:

General Dental Council (2013) Standards for the Dental Team. General Dental Council
https://www.gdc-uk.org/information-standards-guidance/standards-and-guidance/standards-for-the-dental-team/

General Medical Council (2013) Good Medical Practice. General Medical Council
https://www.gmc-uk.org/-/media/documents/good-medical-practice—english-20200128_pdf-51527435.pdf?la=en&hash=DA1263358CCA88F298785FE2BD7610EB4EE9A530

Health & Care Professions Council (2016) Standards of Conduct, Performance and Ethics. Health & Care Professions Council
https://www.hcpc-uk.org/resources/standards/standards-of-conduct-performance-and-ethics/

House of Commons (2018) PIP and ESA assessments: claimant experiences
https://publications.parliament.uk/pa/cm201719/cmselect/cmworpen/355/35502.htm

Nursing & Midwifery Council (2015) The Code: professional standards of practice and behaviour for nurses, midwives and nursing associates. NMC London.
https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf