Risk Alert: Clinical records for clinical matters only

20 July 2010

Consider the following scenario – a patient complaint over medical treatment provided by a GP escalates into a claim for damages. Solicitors acting for the patient ask for copies of all relevant medical records along with a patient consent form. The practice dutifully copies the full record and sends it unaware that included among the documents is correspondence between the GP and a medico-legal adviser from the MDDUS discussing the original patient complaint and the likelihood of a negligence claim.

Such a scenario is not so unlikely and indeed MDDUS can cite genuine cases where something similar has happened.

It is essential that a patient’s medical or dental records are used to keep clinically relevant information only. MDDUS has had many calls over the years from practices who have disclosed full patient records without checking the contents, leading to claims of improper disclosure of non-relevant information and details breaching third party confidentiality (family members).

Among documents commonly misfiled in patient medical records are:

• Medical reports for insurance companies or DVLA, e.g. heavy goods vehicle (HGV) applications
• Case conference meeting minutes regarding issues of child protection or a vulnerable adult
• Correspondence with solicitors including reports for court purposes
• Reports and correspondence regarding employment issues
• Reports for the DWP or benefit agencies
• Correspondence in regard to medico-legal claims or complaints from the GMC or GDC
• Correspondence, notes and reports to do with the investigation and resolution of patient complaints.

Such information – if deemed important to keep – should be maintained in a separate patient file.

The risk of inappropriate disclosure has been further enhanced by the computerisation of patient records. Many practices now have a policy of scanning and storing all patient-related correspondence in electronic folders. To copy and send a folder takes only a matter of seconds. But just as with paper records it is essential such records are thoroughly checked before disclosure.

Clinical relevance is the key consideration when it comes to the medical or dental record. How does the information have a bearing on the health of the individual patient? Some issues such as a child protection order should be noted on the medical file along with any relevant medical information that is not already known, but the minutes of the meetings themselves should not be kept in the medical records as they invariably include details of third parties, such as family members.

ACTION Maintain a separate patient file for essential but non-clinically relevant materials such as patient complaints or medico-legal correspondence. Ensure that whatever files are to be disclosed are first thoroughly checked to ensure no inappropriate information is included such as non-clinically relevant information or details that might breach third-party confidentiality.