Note-Keeping on Expeditions

Dr Craig Miller / Emergency Medicine Registrar / Peninsula

The importance of note-keeping is well documented (pardon the pun). Maintaining good clinical records is the cornerstone of exemplary patient care and should not be overlooked, especially on expedition. This article, the second in our masterclass series, provides an overview of the approach to clinical records and documentation on expeditions.

The context

The General Medical Council (GMC) stipulates that maintaining clear and accurate records is a key responsibility of any doctor providing medical care. These requirements are outlined in ‘Good Medical Practice’, succinctly and clearly.¹ In brief, clinical records should include the following:

• Relevant clinical findings
• The decisions made and actions agreed
• Who is making the decisions and agreeing the actions
• The information given to patients
• Any drugs prescribed, other investigations, and treatment
• Who is making the record and when
• Clear, accurate, and legible information
• A record of the time of events

If your practice is under the governance of the Nursing and Midwifery Council (NMC) or the Health and Care Professions Council (HCPC), both organisations also produce guidance regarding clinical record keeping. This can be found in either the NMC’s ‘The Code’ or HCPC’s ‘Standards documents’.^2,3 These standards can, and should, be applied in the context of wilderness medicine, and should constitute fundamental considerations before and after an expedition.

Prior to the Expedition

Expedition medical planning should take place significantly in advance of departure. Usually this means at least three to six months prior to the departure date. Designing, and deciding how to manage, medical documentation should take place in this planning phase. The discovery of poor medical documentation policies, and an unwillingness to address them, should cause a medic to question their participation in the planned expedition.

During the planning phase there are several considerations with regards to medical documentation:

1. Determine whether the expedition intends to use paper or electronic notes (or both)
   Each note keeping method has its advantages and disadvantages, so consider the expedition setting. Larger expeditions, with a base camp, may favour electronic notes, as they will have the required resources, power and hardware. Smaller, roaming expeditions may be better suited to old fashioned paper notes.
2. Consider protection of your notes from the environment
   Remember water and paper mix poorly. Medical notes are legal documents and should be kept in the best possible condition. Your medicolegal defence is only as good as your notes. Similarly, batteries are rapidly depleted with cold exposure.
3. Consider the documents that will assist your note-keeping whilst on expedition.
   Observation and drug charts, patient assessment proformas, and transfer of care documents improve the quality of documentation within the hospital setting. Consider producing pre-made forms for the expedition. These are extremely useful in austere or challenging environments, or during time-critical incidents to ,ensure all required information is captured.
4. Consider the security of medical information before, during and after the expedition.
   Pre-expedition medical screening creates the first medical notes for an expedition, and these are often electronic. Determine how you intend to store these medical notes securely before, during and after the expedition. Participant’s medical screening should include past medical and surgical history, drug history, allergies, immunisations, and emergency information such as passport/ insurance/ next of kin. This needs to be kept securely, but be readily accessible to the expedition medic. There’s little value in taking this information on expedition if you are unable to locate it in an emergency. Similarly, be wary of accessing this information via the organisation’s headquarters, as this relies on an individual picking up the phone, or answering an email, often out-of-hours or in a different time zone. Patient confidentiality and a difficulty with security clearance over the phone will often limit what information can be given.
5. (Note storage after the expedition is discussed later.)

Clear clinical note management is complemented by other aspects of the expedition preparation. These include documentation focusing on the expedition medical kit and medicine storage, specific expedition guidelines, risk assessments, and a comprehensive emergency response plan.

The British Standard 8848 (BS8848) is the gold standard for expedition planning for UK based organisations.⁴ It’s a huge document but thankfully the Faculty of Pre-Hospital Care have produced an easily digestible review, and this should be read alongside FPHC’s own Updated Guidance for Medical Provision for Wilderness Medicine. ^5,6

During the Expedition

This may be the easiest aspect of expedition medical note management, provided there is commitment to good clinical note keeping. Here are some important considerations:

• Ensure patient details (name and DOB) are present on your documentation, alongside time and date.
• It may be relevant to include specific environmental information: location, altitude, temperature/weather.
• Remember to sign off your documentation with signature, name, and professional registration number.
• If you’re an expedition doctor, don’t forget what our incredible nursing and allied colleagues do every day. Documentation of observations, medicines administered, and personal care should all be recorded.
• You may be the only clinician present, so it is important to document uncertainty in diagnosis and the rationale for decisions around treatment or evacuation.
• If you can’t keep contemporaneous notes, consider asking an appropriate member of the expedition to scribe. Alternatively, use your phone for voice or written notes which you can transcribe later.
• Document discussions with the expedition leadership team, medical supervisors and patients . This is of paramount importance when there are areas of conflict. For example, sending a participant down from a seven summits attempt due to altitude illness, or when health takes precedence over other agendas.
• Adverse or serious incidents require additional documentation and should include a factual history of what happened and when, what actions were taken, and the resultant outcome.
• Detailed notes may be necessary for insurance claims for the patient, and will benefit you if you are asked to write a report to support their claim.
• Remember photos and videos can be helpful adjuncts to your written clinical notes. For example, ongoing care of a wound. These must be securely stored and can only be taken with patient consent.
• Additionally, photography at the scene of a major trauma scenario may seem like a breach of confidentiality, but if sensitively conducted may later help the patient to process and recover from the event.

Some expedition companies provide a template for assessments, or you can make your own to take with you.

After the Expedition

Upon returning home from a (hopefully!) successful expedition, your responsibilities as a wilderness medic aren’t over yet. Depending on the events of the expedition, you may be required to contact a participant’s GP if there have been any clinically significant illnesses that require onward care or further investigation. Furthermore, it is also important to write a letter to a participant’s GP regarding significant although resolved episodes, so they are able to update their permanent medical records. For example, a dislocated shoulder which has been relocated on expedition.

Additionally, the post-expedition report may require a breakdown of illnesses and injury diagnoses that occurred. This helps the organisation to tailor their medical kit and tweak risk assessments for future, similar expeditions. Once you’ve completed any necessary GP letters, and finalised the post-expedition medical report, consider the storage of expedition medical notes. Unsurprisingly, the GMC has advice on this;⁷

“You must keep records that contain personal information about patients, colleagues or others securely, and in line with any data protection law requirements.”

There are several pieces of guidance and legislation to be aware of when considering medical documentation storage. These include:

• The GMC’s ‘Good Medical Practice’ and ‘Confidentiality: good practice in handling patient information’ ^1,7
• General Data Protection Regulation (GDPR)⁸
• Health and Social Care Act (2012)⁹
• NHS Records Management Code of Practice (2021)¹⁰
• The Private and Voluntary Health Care (England) Regulations (2001)¹¹

As discussed, the GMC determines the professional standards with regards to medical documentation. The other pieces of legislation or guidance refer to the legal requirements of clinical note storage both within the NHS and private practice. This legislation and guidance is limited to UK jurisdiction, and most expeditions occur outside of these areas. However, it can be reasonably assumed that these documents would be the standard for practice in expedition settings. For example, for a UK doctor the GMC’s guidance holds true for other aspects of expedition medical work, even if outside the UK.

This is a complex area, but the bottom line is that medical documentation should be stored, post-expedition, for a minimum of 8 years. In addition, there are also conditions under which the notes should be held. Correct and proper storage of medical notes is the primary responsibility of the ‘data controller’, which is the individual or organisation who is tasked with storing the notes. The clinician should be content that their notes will be held appropriately by the organisation’s ‘data controller’. Importantly, GDPR determines that medical documentation should be:⁸

“processed in a manner that ensures appropriate security of the personal data, including protection against unauthorised or unlawful processing and against accidental loss, destruction or damage, using appropriate technical or organisational measures.”

As such, it is important to determine, when accepting an expedition medic position, who will be responsible for medical note storage post-expedition. This may be straightforward if travelling with a large organisation, as they should have a suitable system and policy in place, but don’t assume and do check. If it is a smaller expedition, be aware that you may be required to be the ‘data controller’, which comes with significant responsibility and commitment. For more information and advice, speak to your defence union.

The Medical Protection Society (MPS) were approached for comment and provided information relevant to storage of medical notes which aligns with the above information. The Medical Defence Union (MDU) also produces guidance on record keeping.¹² Both are happy to be approached for assistance.

Take home messages

• Remind yourself of your professional body’s expectations for good note keeping.
• Decide how you intend to create and store notes for the expedition, and tailor this to your environment.
• Medical notes require storage for 8 years post expedition.
• Consider who is the ‘data controller’ when planning the expedition, as this determines who is responsible for storage of all medical notes from the expedition.
• Contact your medical defence provider to clarify any legal elements of clinical note storage.

References

1. General Medical Council (2013). Good Medical Practice. Available at: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice (Accessed August 2023)
2. Nursing and Midwifery Council (2015). The Code. Available at: https://www.nmc.org.uk/standards/code/ (Accessed August 2023)
3. The Health and Care Professions Council (2023). Standards: Record Keeping. Available at: https://www.hcpc-uk.org/standards/ (Accessed August 2023)
4. British Standards Institution (2014) BS8848: Safer adventures: Managing the risks of adventure travel. Available from: https://www.bsigroup.com/localfiles/en-gb/consumer-guides/resources/bsi-consumer-brochure-adventurous-activities-uk-en.pdf (Accessed August 2023)
5. Royal College of Surgeons of Edinburgh (RCSEd): Faculty of Pre-Hospital Care (2020). A brief review on BS8848: 2014 and its relevance to new or inexperienced expedition ‘medics’. Available at: https://fphc.rcsed.ac.uk/media/2966/bs8848.pdf (Accessed August 2023)
6. Royal College of Surgeons of Edinburgh (RCSEd): Faculty of Pre-Hospital Care (2020). Updated guidance on medical provision for wilderness medicine. Available at: https://fphc.rcsed.ac.uk/media/2781/updated-guidance-on-medical-provision-for-wilderness-medicine.pdf (Accessed August 2023)
7. General Medical Council (2017). Confidentiality: good practice in handling patient information. Available at: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice/ (Accessed August 2023)
8. General Data Protection Regulation (GDPR). Available at: https://ico.org.uk/for-organisations/uk-gdpr-guidance-and-resources/ (Accessed July 2023)
9. Health and Social Care Act (2012). Available at: https://www.legislation.gov.uk/ukpga/2012/7/contents/enacted (Accessed July 2023)
10. NHS Records Management Code of Practice (2021). Available at: https://transform.england.nhs.uk/information-governance/guidance/records-management-code/ (Accessed July 2023)
11. The Private and Voluntary Health Care (England) Regulations (2001). Available at: http://www.legislation.gov.uk/uksi/2001/3968/contents/made (Accessed August 2023)
12. Medical Defence Union (2013). Good record keeping. Available at: https://www.themdu.com/~/media/Files/MDU/Publications/Guides/UPDATED%20Consultant%20pack/B4%20Good%20record%20keeping.pdf (Accessed July 2023)