RECORD KEEPINGASFASF

Gaynor KynastonLegal and Risk Services

CIVIL CLAIMCIVIL CLAIM

CIVIL CLAIM Breach of duty of care

+

Causation/material contribution

+

Loss/Damage

All three = LIABILITY

BREACH OF DUTY Bolam test

“A doctor is not negligent if he has acted in accordancewith a practice accepted as proper by a responsible bodyof medical men skilled in that particular art”

The practice must have a logical basis

CAUSATION Proof that breach of duty caused injury

‘But for’ test‘But for’ test

Standard of proof - Balance of probabilities49/51%

Material Contribution Bailey v MOD and Another [2008]

Weakness caused death

What caused the weakness?

Anything more than negligible

Bailey v MoD and Another[2008] ERCP – Gall stones – peri op bleeding

Recovery charts/med records

Post ERCP pancreatitis

Gastroscopy + PTC + biliary drainage Gastroscopy + PTC + biliary drainage

Torn liver

Further surgery PEG

Aspirated

Permanent brain damage

Record keepingRecord keeping

Why is record keeping important?

Legal requirement

Requirement of youprofessional body

Identifying risks/controlmeasures

Audit

Research

Communication

Evidence of care providedmeasures

Continuity of care

Education and training

Evidence of care provided

Complaints/litigation

What do I have to do? Standards that pharmacy professionals must follow:

YOU MUST:

1.8 Keep full and accurate records in a clear and legible form

2.4 be prepared to challenge the judgment of others2.4 be prepared to challenge the judgment of others

Recognise and act within the limits of your own competence

5.4 learn from assessments, appraisals, performance reviews andeducation and training

5.5 keep evidence of training and CPD

7.5 be clear of responsibilities when working in a team

7.8 do not stop others from complying with their obligationos

What is a record? Handwritten clinical notes

Emails

Letters

Lab Reports

X-Rays

Incident forms

Photographs

CCTV

X-Rays

Drug Charts

Care Plans

Printouts from monitoringequipment

Practicalities Accurate with clear meaning

Clear, factual, concise andstraightforward

Legible

Chronological

Up to date

Retrospective record.

Black ink Legible

Relevant

Signed/Initialled/Printed/Status/Number

Contemporaneous

Date and Time

Black ink

Altering Records

Keep Originals

Draw a line through the information you want todelete, it should still be readable

Sign and date alterations Sign and date alterations

You should ensure any alterations made and theoriginals are clear and auditable

Common problems

Lack of clarity

Illegibility

Failure to update – risk assessments

Missing information Missing information

Spelling Errors – Inquests

Inaccurate records

Lack of essential detail

Common problems contd.

Too much jargon

Carelessness

Failure to document

Conversations Conversations

Care given

Special requirements

Telephone conversations

Incidents

Consequences of poor recordkeeping

Poor communication

Inappropriate care

Professional misconduct – altering records Professional misconduct – altering records

Prevention of/delay in delivery of care

Substandard care

Consequences of poor recordkeeping contd.

Wrong treatment - Prendergast

Complaint

Litigation – costly to the Health Board Litigation – costly to the Health Board

Brain Injury

Death

Ask yourself Can you explain and justify your actions/decisions?

Will your memory be accurate?

Clin neg/PI claims can be brought up to 3 years fromincident/date of knowledgeincident/date of knowledge

In children up to 3 years after they have reached theage of 18.

Common Legislation governingrecords

Data Protection Act [1998]

Freedom of Information Act [2000]

Access to Health Records Act [1990] Access to Health Records Act [1990]

Civil Evidence Act [1995]

Thank you for listening