Medical, Legal and Health Policy Pressures
The UK’s General Medical Council’s current guidance for good medical practice states that physicians must keep clear, accurate, and legible records that report relevant clinical findings, the decisions made, the information given to patients, drugs or other treatment prescribed, and identify who is making the record and when. This goes on to say that notes may become important later if there is a complaint or claim, which can be made months or years after a consultation.
When you look at what is recorded in the patient note, the impact of not following this guidance is easy to see. Let’s take low back pain, something I am confronted with regularly when treating patients. This type of pain is complex and there is a great deal of information that should be recorded in a patient’s note. Pertinent information includes how long the patient has suffered with the pain, how and when it started, the specific symptoms, if there are any red flags, what treatment has been offered, whether they have tried physiotherapy, and other remedies they have tried themselves. However, in a busy practice, you will find that many GPs don’t have the time to record this level of detail so it never makes it into the patient health record. This is increasingly a problem as patients become more litigious.
In the past, not recording this information in clinical documentation might have been workable given that the majority of patients in primary care were typically looked after by the same doctor over time who provided continuity of care. Unfortunately, this is increasingly not the case in today’s healthcare ‒ in the National Health Service (NHS) and many other countries. There is an inevitable negative impact from this lack of continuity of care on our patients who are increasingly frustrated when they have to constantly repeat the same story to different clinicians. With consultation times short, having to repeat histories may not be an effective use of time and puts people at risk.
Patient information Online
The NHS Five Year Forward View makes it clear that physicians need to treat patients in a more holistic way. This calls for many changes including more integrated models of care and the breaking down of barriers between tiered health services and social care. Inevitably this will increase the need for better communication between healthcare professionals, as well as with social services, and clear and comprehensive documentation will become even more imperative.
One clear intention is to allow patients to have access to their records online. This view into their own personalized health and care record online has already happened in some areas of primary care. To avoid complaints, GPs and health professionals may have to be more careful in what they document so as to remain accurate, but also avoid insulting their patients ‒ in other words writing more subtly.
Increasing Productivity and Quality
All of these changes require health professionals and the NHS to focus more on patients’ needs and their outcomes. This becomes more difficult with changing working patterns and the loss of the same GP who consistently sees his/her own patients. This will require better communication between GPs, health professionals and social services. Entering consultations into the patients’ electronic notes, rather than via letters, will be the main way that this communication will increasingly occur, and clinicians will need to document histories in greater detail.
These are things, which as a GP in the north of England, I take very seriously. Working in prisons and in the community has given me insight into how these more integrated models of care will impact the community, both positively and negatively. In terms of history taking and documentation, in order to improve patient outcomes, my colleagues and I will have to capture more detail about the lives of our patients and subtle aspects of what our patients tell us during the consultation. When we do this, my personal experience has been that patient outcomes and patient safety have improved.
So how do GPs ensure this level of detail is recorded?
I taught myself to touch type, so I’m fairly quick. However, I prefer to use to get as much detail as I can into patient notes. I believe that it makes me more effective; I can add a greater level of detail in less time and with less stress. A recent research paper by Dr. Markus Vogel and colleagues confirmed this is the case with many physicians. Researchers found that documentation speed increased by over a quarter, the amount of information documented was greater, and doctors using speech recognition were happier.
Sometimes I find it is beneficial to take a step back to see the bigger picture and how small changes to everyday practice can make a big difference. I believe this one solution will ultimately improve patient records, patient care and help me feel less stressed as I deal with shifting work environments.