Defining a health record
In today's healthcare settings handwritten records are still common but patient records and data are increasingly being created, maintained and stored in electronic formats and can take many different forms. The Data Protection Act 1998 defines a health record as:
"Any electronic or paper information recorded about a person for the purpose of managing their healthcare" section 68 (1) (a)
This can include a range of different records from the multidisciplinary team e.g.
- Care Plans
- Hand written hospital nursing and medical records
- G.P. and other members of the primary health care team records
- Outpatient records and examination/test results/monitoring equipment print outs/ photographs of the patient
- X-rays, pathology other laboratory records
- Digital/electronic records
Patient records include traditional communications with the patient such as letters to and from the patient or their G.P. and other information and communications relating to the patient e.g.
- emails
- video
- tape recordings of nursing handovers
- telephone conversations
- text messages relating to the patient
All of these records describe the care delivered to, and received by, the patient and as such can be used as evidence in any investigation into the care of the patient. Should legal proceedings arise as a result of an investigation, all or any of these can also be called as evidence in a court of law with the individual healthcare practitioner being required to defend their decision making and interventions in relation to any patient care provided.
Griffiths & Tengnah (2010) highlight how the views of the patient or relatives are also an important source of information in relation to the patient status and progress. Relatives know the patient very well and may be in a position to detect changes in the patient demeanour or condition in advance of the healthcare professional. The need to acknowledge, record and act on these views is highlighted in the case of Mrs M and Mr N v Hastings and Rother NHS Trust (Audit Commission, 1999).
Concerns raised by the relatives of a man who subsequently died from an intestinal obstruction were not recorded in the patient notes and not acted upon by the staff caring for the patient. The Ombudsman reviewing the complaint made by the patients relatives, considered this to be a significant oversight by the staff, which if recorded at the time, could have been acted upon by the staff and may have prevented the delay in treatment for this patient which ultimately contributed to his death.
