Medical records

DR Claire bonello's piece on medical records (The Sunday Times, August 21) is of great interest to lay people and professionals alike.

Medical records are far from mere scribblings. Most agree they are highly important documents reflecting the quality of medical services dispensed by individual doctors and the hospitals, clinics or other institutions where doctors work.

Medical records are often made up of several documents like the patient's clinical history, including observations of his or her clinical course, charts of important clinical parameters, like temperature and fluid balance charts, X-rays and other forms of imaging investigations like ultrasound, together with their reports, blood and other body fluid investigations, collected in one medical file bearing the patient's name, his or her ID, and the name of the hospital, or clinic where the treatment was received.

Such an assemblage of personal, highly sensitive and confidential information can, in cases of major clinical importance, form thick dossiers, which call for proper handling and archiving. It is this body of personal information to which the Data Protection Act is addressed and the care of medical files is, in most developed countries, the direct responsibility of the records officer, a highly trained and senior hospital official.

This, of course, does not preclude any doctor who is part of a team of health care workers treating a patient from making personal clinical notes of the course of an illness in which he is particularly interested, for his own study and research provided he observes all the guidelines regulating such matters as confidentiality and careful custody.

The doctor is also certainly not required to take personal notes if he does not feel so inclined, provided he enters his part of the clinical management in the official hospital medical records.

It is this distinction which, with all due respect, Dr Bonello's article fails to make and which has a direct bearing on the conclusions of the Data Protection Commissioner reported on the same page with which I disagree.

Volumes can be written on the subject of medical files, but one point which is of high forensic interest must be made. I shall not go into other important aspects such as the medical file as a tool for research, secondary medical records like the Register of Operations held in every operating theatre, etc.

A person's medical file is of crucial importance in the event of a judicial inquiry into a grave, untoward outcome of a case. In the usual course of events in Malta, the inquiring magistrate selects one or more medical experts to report on the case and the experts so appointed are after due application given the facility to retrieve and examine the relevant medical file.

When they are finished with it and have drawn up and filed their report with the inquiring magistrate, the medical file is returned to the hospital or to the magistrate concerned. Should a public hospital be involved in the inquiry, it is not unusual for the health authorities to ask the magistrate to examine the report submitted by the experts and recall the medical file and keep it for as long as they wish; the inquiring magistrate and Attorney General often go along with all this.

This is a most irregular and reprehensible practice which can give rise to a stultification of the judicial process. Witnesses and the medical file may be interfered with before a trial begins; and I say this advisedly.

Finally, it is good to point out that it is not up to the Medical Council to lay down guidelines as to what and how medical notes are set down in the medical file. That is the job of the consultant in charge, who is responsible for seeing that all the relevant clinical information is recorded, the appropriate charts are set up and updated and all the results of the various investigations gathered and kept in order.

Which goes to show that a medical service such as that provided by St Luke's Hospital, and of which we are all proud, must have a staff of consultants which, besides being highly competent in their craft, also have a host of other duties, including that of training and supervising the more junior members of their firm.