The increase in negligence litigation against doctors in general, and obstetric anaesthetists in particular, has led to increased concerns about the standard of record keeping in hospitals. Many hospitals now have clinical risk managers, and one of the main tasks of these individuals is to ensure that records are clear, complete and retrievable. Many practitioners criticise the current medicolegal climate as leading to the practice of ‘defensive medicine’, but in the area of record keeping at least, the benefits for practitioner and patient alike are clear. There is no doubt that record keeping has often been poor in the past, and that this has led to delays, unnecessary repetition of investigations and breakdowns in communication.
Increasingly, certain aspects of medical record keeping are being done electronically (e.g. prescribing, recording of intraoperative observation) but the unpredictable nature of obstetric analgesia and anaesthesia makes such systems difficult to design and implement in the maternity setting.
Special considerations
Legibility
Although it is not always easy to maintain good legibility in the emergency situation, every effort should be made to ensure that entries in the notes, and particularly signatures, can be read. While most doctors can read their own handwriting, this is not always true 20 years later, and it should be borne in mind that the interpretation will often be made by someone other than the writer. Each signature in the notes should be followed by the author’s name in capital letters.
Hospitals rarely release original notes, and solicitors usually receive a photocopied bundle of records, often prepared in haste by the most junior office assistant. Therefore, black ink (it photocopies better) should be used, and notes should not be written in the extremes of the margin (often missed in the photocopying process).
Contemporaneity
The courts appreciate that it is often impossible to keep good, contemporaneous records in the midst of dealing with a crisis. It is perfectly in order, for example, to copy a series of blood pressure results from the monitor ‘trends’ screen into the record after an operation. Similarly, it is quite reasonable to sit down after a dangerous situation has been stabilised and make a retrospective record of what happened - in this instance, however, the time at which the record was written should be included in the entry. It is even acceptable to go back and alter or add notes some time after the event - as long as the alterations are honest - but it must be made very clear in the notes that these are later additions. In general, complex notes should be made as soon as possible after the event, while the memory is fresh.
Completeness
While it may be one’s standard practice to warn of the risk of headache before siting an epidural or to assess the level of block after instituting spinal anaesthesia for caesarean section, it is prudent to note that this has been done in each individual case - and ideally, this record should include the incidence quoted. An anaesthetist’s actions may be queried many years after the event, by which time he/she will have no recollection of the individual case; the patient, on the contrary, will remember it as if it were yesterday. In this situation, the defence that something must have been done, because it was one’s routine practice always to do so, does not carry much weight if there is no mention of it in the notes.
Reasons for making clinical decisions - such as withholding a blood patch for a postdural puncture headache because it seems to be improving - should always be carefully noted, especially when the decision deviates from standard guidelines. Finally, all entries should be dated, timed and signed legibly.
The maintenance of complete records can be encouraged by developing forms with prompts for commonly omitted data, such as level of block and mode of testing after regional anaesthesia. Good record keeping can also be encouraged by stressing its value in departmental guidelines. One of the most effective methods for ensuring standards is to incorporate a review of clinical records into the audit programme.
Retrievability
The best records in the world will be of no help if they cannot be found. Anaesthetic notes, especially epidural forms, are often made on sheets that do not form part of the main record. There must be a system in place for incorporating these into the bound folder, preferably not by just inserting them into a pocket in the back.
Obstetric litigation may arise up to 21 years after the birth of the child. Maternity records must be kept for at least this long, and this often causes considerable logistic problems, as does the difficulty in tracing the practitioners involved after such a long period.
Key points
• Notes should be written clearly and legibly in black ink.
• The date, time and the author’s name should be included.
• Even if a practice is routine, details should be noted.
Further reading
McCombe K, Bogod DG. Learning from the law: a review of 21 years of litigation for pain during caesarean section. Anaesthesia 2018; 73: 223-30.