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Importance of keeping contemporaneous medical notes
5 September 2023
Toni Hall, a newly qualified Solicitor in the Clinical Negligence Department considers the importance of keeping contemporaneous medical notes.
Medical records are made to support safe and effective medical care. They help to facilitate and maintain communication between clinicians that in turn helps maintain the continuity of treatment.
Contemporaneous records simply means records were created at the time of the medical care received, so that they should be an accurate reflection of what occurred at an appointment or during a procedure for example.
Such records are also the foundation of any claim for clinical negligence. They are the starting point for any investigation as ultimately, they tell the story of the care a patient received. They are then used to determine whether the care received was reasonable. It is therefore in a clinician’s interests to ensure that they record thorough notes regarding the patient’s care.
The importance of keeping contemporaneous records was clearly highlighted in the case of CDE v Surrey and Sussex Healthcare NHS Trust  EWHC 2590 (KB). The Claimant was born by emergency caesarean section and suffered acute profound hypoxic ischaemia before, during and after her birth. She was subsequently diagnosed with severe global developmental delay; suffered seizures; had to be fed by tube and was categorized at the most severe level on the Gross Motor Function Classification System.
The issues in dispute were:
- Did the Defendant fail to provide a reasonable standard of care to the Claimant by failing to transfer her mother to the labour ward or delivery suite 40-50 minutes earlier j
- Did that failure lead to a delay in the performance of the emergency caesarean section that was eventually carried out? The Claimant asserted that it should have been carried out 4-7 minutes earlier.
- Did any such delay increase the acute profound hypoxic ischaemia suffered by the Claimant and so cause, or materially contribute, to her cerebral palsy?
Lord Justice Stuart-Smith confirmed that the starting point to decide on what happened during the course of the antenatal period, labour and delivery should be determined from the medical records. He made the following comments:
“…The medical notes were made by trained professionals who realised or should have realised that their medical notes represent the primary contemporaneous record of the events and that each separate note should be timed and signed so that other clinicians can understand what has happened and when it occurred and who was involved in the treatment of M and the baby…”
The default position in clinical negligence claims is often that if something is not recorded in the records, then it did not occur. This may mean that something has been missed in a patient’s care. Should everything be recorded, then the treating clinicians are fully aware of the patient’s condition, medications, treatments and investigations and then are then able to make an informed decision on the care plan going forward. Therefore, contemporaneous records also have ability to narrow down any contentious issues and provide a defence.
From a Claimant’s perspective, contemporaneous records are beneficial in terms of investigating a claim. Some claims involve comparing medical records with clinical guidance. Where a clinician has kept contemporaneous records, their thought pattern and judgement behind the decision can be seen which in terms helps us to determine whether or not it followed guidance or had a reasonable reason for departing from the guidance.
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