link to article in The TIMES
Medical records - not just mundane scribblings
In recent weeks, the medical matters which have concerned the Maltese public have been the possible onset of an avian flu pandemic, the issue of cardiac surgeons' salaries and the heartbreaking death of a 19-month-old girl.
Certainly not much attention has been directed towards another aspect that falls within the realm of medical professionals - that of the drawing up and retention of medical records. Yet, even a seemingly mundane matter such as the proper keeping of records might have serious repercussions on a patient's health and well-being, and should not be dismissed lightly.
Medical records are primarily kept so that a patient's condition can be documented and care planned accordingly. Accurate and complete information is vital to ensure that patients receive appropriate treatment. The proper retention of records is becoming increasingly important in view of the shift towards a multidisciplinary health care system where different health professionals might be involved in the treatment of a single patient. Within such a system, it is evident that a complete set of records must be available to be handed over to each successive professional to ensure a seamless treatment plan.
Within a wider social context, the consequences of inadequate patient data is illustrated by the very sad case of Victoria Climbie in England. Here, a young girl died after several years of torture and abuse which was missed by healthcare professionals partly through insufficient information sharing. Even if her records had actually been disclosed to the appropriate people and officers involved in her case, it may still not have been enough due to the limited extent and quality of the information.
Although it would seem that records are to be kept solely for patients' benefit, this is not really the case. They may constitute evidence that is essential for a physician's defence in the course of a malpractice suit. Records will show that a physician has in fact carried out requisite examinations and prescribed medicinals on specific dates - all details that may prove to be pertinent in the course of litigation.
In the light of the above, it would be in order to see what the situation obtaining in Malta is when it comes to the drawing up of medical records, and whether a patient's right of access to his/her medical records is adequately safeguarded. It would seem that there are no statutory guidelines as to the type or extent of information, which a physician is to keep about the patients under his care. This is left to his discretion.
While the taking of copious notes is obviously impractical for those practitioners who examine a large number of patients suffering from minor ailments daily, very scant notes or a failure to record any details of the symptoms described by patients might lead to a situation where vital details are missed by successive doctors, with disastrous results for the patient. Statutory guidelines issued by the relevant professional body - the Medical Council - could lay down the minimum amount of information that should be taken down by physicians, ensuring a safer scenario for all.
Even if all the relevant information about a patient is conscientiously taken down by a physician, it is useless if lost and unavailable for the patient, or for other physicians whom the patient would like to consult. Contrary to common perception, the patient does have a right of access to medical records about him.
If this was not so, he would be unable to pass these on to other physicians for a second opinion. This is in line with what is stated in the American College of Physicians' Ethics Manual - namely, that while the actual medical chart is the property of the physician who compiled it, the information contained in the chart is the property of the patient. So a patient has every right to request his medical records.
Unfortunately, it would seem that patients claiming that this right be safeguarded are given short shrift by the Medical Council. As shown by the case study highlighted below, when a patient requested those records drawn up by a consultant surgeon, the council completely ignored the matter and did not provide an explanation for this.
The patient in question feels irked at the council's attitude, sensing that the matter was considered to be too trivial for the council's intervention. Yet, what would have been the situation of the patient had she wanted to be treated by another physician, and essential records not been forthcoming?
No amount of pecuniary damages could be an adequate substitute for the time lost for new medical records to be compiled in such a case. It is felt that in this case the Medical Council has completely disregarded patients' rights when it comes to the retention of medical records by practitioners.
Such an attitude does not bode well for patient-doctor relationships and the trust that the public places in practitioners. For patients to be sure that they are receiving the best of all possible care, they have to be ensured that even the mundane matters. Keeping proper medical records and providing access to them is an elementary part of this equation - but a vital one.