THE BIG QUESTION

THE BIG QUESTION

Patient records: electronic or paper?

In an increasingly digital age, is there any need for paper files? Are electronic records better for managing patient information?

DAVID HOLLAND Chartered Scientist and podiatrist expert witness in Wales

I keep written and duplicate electronic records according to legal requirements. Legal records and evidence documents are often produced on paper but sent out electronically. The clinical records I see, particularly hospital records, are usually handwritten. I had clinics at Nuffi eld and Spire, and both were keen on handwritten records.

There is an advantage in having hard copies. According to an article by ARE Taylor, Future-proof: bunkered data centres and the selling of ultrasecure cloud storage, while the cloud is well-protected against cyber crime, some cloud storage is not well protected against theft of servers. Storage in obsolete nuclear bunkers is secure against cyber and all other forms of criminal damage or theft. There is an argument for having a hard copy backup, but it comes with the responsibility of safe disposal. A good cross-shredder is an absolute must.

TAKE THE COURSE

To access the College’s record-keeping course and webinar on its teaching and learning update system (TALUS), go to bit.ly/college-academy. If you have queries on record-keeping, contact

professionalsupport@cop.org.uk THOMAS CALDERBANK Managing director of Care Home Podiatry in Lichfield

Working exclusively in the care home sector, electronic records are essential to the way we work. They allow us to have up-to-date information on our patients –whether we’re out on visits or receiving queries at the offi ce, while eliminating the data security dangers of carrying paper records around.

We love the ability to complete a patient’s notes at the bedside on a smartphone – it makes our notes more accurate, and we think there are fewer infection control risks than if we were carrying paper records around.

We’ve also been able to automate some of our administrative functions, such as sending outcome letters to be added to care plans. We can auto-populate letters straight from our clinical notes, without duplicating the work. It’s a real time saver.

KATIE COLLINS Professional support off icer at the College

Healthcare professionals must keep patient records for anyone they treat. Whether they’re electronic or paper is down to personal preference, but they must comply with legislation, which the College Clinical Standards of record-keeping and consent explain. See bit.ly/standards-of-practice (log in fi rst). One of the main issues we fi nd with paper notes is illegibility, and this is where electronic notes can help immensely. Electronic patient notes have to be compliant with the Information Commissioner’s Offi ce (ICO), and you need to be registered with the ICO. Now many electronic systems also have the added advantage of recording digital signatures, making consent even more streamlined without the need for reams of paper. Whichever way you record patient notes, ensure they are in-depth and comply with our standards. Some 80% of litigation and HCPC cases we see have poor consent and record-keeping at the heart of them.