Keeping good documentation: the ethical and legal issues in medical records

Opening Vignette

Doctor B is a consultant surgeon in a restructured hospital. Recently, his wife saw a gynaecologist at another restructured hospital and was anxious to know the laboratory results before her next appointment. She asked her husband to check her results on the National Electronic Health Record (NEHR). The next day, Doctor B logs in to the hospital’s electronic health system, enters his wife’s NRIC number, accesses her NEHR record, and prints out her latest laboratory results.

INTRODUCTION

Medical records have been an essential part of healthcare for thousands of years, with their roots tracing back to ancient civilisations. Over time, the purpose and format of medical records have evolved significantly. This article analyses the history, ethical basis, good practice and legal perspective of medical records. We will discuss electronic health records (EHRs) and highlight the recent draft of the National Electronic Health Record (NEHR) guidelines in Singapore.

HISTORY OF MEDICAL RECORDS

The history of medical records spans thousands of years, beginning with ancient civilisations. In the 17^th to 16^th centuries BC, an Egyptian case report of a surgical procedure was recorded on papyrus scripts. Initially, in the 17^th to 18^th centuries, medical records were primarily used for educational purposes in Paris and New York. However, by the 19^th century, their role had expanded to insurance and legal purposes. The transition to EHRs began after 2000. This digital revolution encompasses various aspects such as radiological images, laboratory results, prescriptions, outpatient and inpatient notes, and clinical notes in private clinics. With the rapid development of artificial intelligence since 2020, it is foreseeable that medical records will soon undergo another transition.[1]

ETHICAL BASIS OF MEDICAL RECORDS

Keeping good medical records is a practice rooted in professionalism and ethics. Doctors produce two types of written communication: internal medical records containing the content of consultations and external professional communications such as correspondence to other agencies and medical reports for legal and insurance purposes. These records benefit patients by ensuring continuity of their healthcare and fostering collaboration for their social welfare. Therefore, accurate, contemporaneous, thorough, honest, objective and neutral documentation in both medical records and professional communications is essential to uphold patient autonomy and beneficence.[2]

Good medical documentation shows the depth and value of clinical judgement. In addition to the usual objective findings from history taking, physical examination, investigations and management plans, it is advisable to include the values of both the doctor and patient or family in modern medical records. These subjective beliefs, concerns and values reflect both parties’ assessments of the patient’s preferences, quality of life and other relevant contextual factors. By doing so, a doctor incorporates both medical information and ethical considerations into the medical record, following the commonly used Jonsen’s ‘four-box method’ of clinical ethics.[3] Eventually, a medical record serves as a visible expression of medical professionalism and a patient’s dignity. It also illustrates the spirit of professional accountability. In case of a complaint or legal dispute, the documentation of objective findings, the pros and cons of various treatment options and relevant ethical considerations will be crucial for the assessment of the standard of healthcare delivery. Furthermore, clear and accurate clinical documentation is fundamental to the quality of clinical education and the integrity of biomedical research.[4]

In Singapore, the Ethical Code and Ethical Guidelines (ECEG) (2016) issued by the Singapore Medical Council provide a specific section on medical records in section B3. It indicates the importance of maintaining clear, legible, accurate and contemporaneous medical records with sufficient detail to enable high-quality continuing care.[5] A companion resource — The Handbook of Medical Ethics — expands some points in ECEG section B3 with detailed explanation and illustrations.[6] These two documents are essential resources for guiding ethical medical practices locally.

GOOD MEDICAL RECORD PRACTICE

Good medical record practice enhances clinical judgement and supports continuity of care when the healthcare information is accurate and relevant. Doctors constantly worry about the amount of information required for their medical records. In 2015, Dutch scholars conducted a Delphi study among internal medicine clinicians to determine which therapeutic information is essential to include in a medical record.[7] From 26 registrars and 30 consultants, they identified the following items: diagnosis/problem, non-drug therapy, drug therapy (name, strength, dose, dosage form), start and stop dates, reason for drug (if contraindication/interaction is present), patient’s awareness of the given information and arrangement of monitoring appointment. This list highlights the key medical facts and information that doctors consider crucial for future reference and continuity of care. However, this list reflects solely the perspective based on clinicians’ interpretation of medical facts and scientific evidence.

In modern medical practice, patient involvement is paramount. With the decline of medical paternalism and rise of patient autonomy in clinical decision-making, contemporaneous and succinct documentation of consultations is essential to facilitate communications among healthcare professionals and to assist in potential future disputes. Hence, incorporating elements of ethics in medical records can enhance professionalism by reflecting the values inherent in the doctor–patient relationship and clinical consultation. In short, the symptoms, signs, laboratory, imaging and histology results do not convey the subjective dimension, particularly the patient’s understanding and interpretation of medical facts.

To strengthen and clarify the moral domain of medical records, Tauber[8] suggested including a section on ‘Ethical Concerns’ to medical records, enabling clinicians to maintain reflexivity through an ‘Ethical Work-Up and Diagnosis’ aimed at achieving patient-centred medicine. Applying the four-box practical approach by Jonsen et al.,[3] the medical record of each consultation will consist of two parts: the ‘epistemologies’ of care (medical assessment, diagnosis and treatment options) and the ‘ethics’ of care (patient’s preference, quality of life and contextual features). As ethical reasonings, concerns, values and analyses will be captured more explicitly, it encourages clinicians to be more self-reflexive on the ethical, legal, societal and personal contexts of the disease and treatment. It is sensible that Tauber recommended this approach to improve clinicians’ attitudes towards moral reflexivity, rather than just considering healthcare ethics in crisis management or in the pedagogy of clinical ethics education.

LEGAL PERSPECTIVES OF MEDICAL RECORDS

Beyond clinicians’ self-reflexivity of ethics and professionalism, detailed documentation of the doctor–patient discussion on the diagnosis and treatment options serves as a critical basis for legal litigation, e.g., negligence claims. Complaints and lawsuits usually come months or years after the consultation and treatment; both the patient and doctor may have difficulties recalling what has (or has not) been mentioned. The Court of Appeal of Singapore, in Hii Chii Kok v Ooi Peng Jin London Lucien,[9] observed:

“What information a reasonable person in the patient’s position would have likely attached significance to should be answered by reference to the time at which the relevant decision… and not at a later time.” [para 161]

Therefore, an appropriate documentation of the doctor–patient discussion at the time of clinical consultation is paramount — not just the medical symptoms, signs, investigation results, diagnoses and treatment options. Chief Justice Sundaresh Menon, in the same judgement, advised that:

“There could be situations of ‘forgetful patients’ who, perhaps under the fog of illness, deny that they were ever apprised of a risk. In our judgement, this phenomenon does not detract from the need to ensure that patients are sufficiently well-informed so that they can provide informed consent at the material time. Rather, the solution, if at all, lies in improving methods of documenting the information that the doctor imparts to the patient and keeping appropriate medical records of such discussions.” [para 162]

ELECTRONIC HEALTH RECORD

Since 2000, hospitals and clinics in many countries have progressed to electronic medical records (EMRs). Komesaroff and Kerridge[10] observed that increasing healthcare and therapeutic complexity, population mobility, the shift from hospitals to community care, the rise of team-based and multi-specialty practice, and the evolution of the Internet have placed immense pressure on EMR storage and prompted a reconceptualisation of medical records. The context of consultation and doctor–patient discussion has become increasingly important amid ethical transitions in the modern era: from paternalism to patient autonomy, from a confidential, trusted relationship to the need to protect personal privacy, from research as an ancillary support to an integral part of clinical care, and from medical treatments confined to hospitals and clinics to rapid changes driven by disruptive technologies.

In such a complex contemporary world, EHRs may reduce discontinuities and errors in care (e.g., drug allergy), enhance compliance to clinical guidelines and integrated clinical decision support (e.g., use of clinical pathways), and facilitate communications among healthcare professionals and patients (e.g., patients’ use of smartphone apps to monitor appointments, results and medications). However, the complex inputs from multiple healthcare professionals and institutions, widespread access to patients’ confidential information, and the use of voluminous EHRs within brief consultations raise ethical and legal concerns.[11] What if the EHR is inaccurate? Who is permitted to access it, and how? Does the increased accessibility of patient health information impose any additional duty of care? In view of these concerns, a Ministry of Health (MOH) committee has recently drafted a new guideline.

NATIONAL ELECTRONIC HEALTH RECORD GUIDELINES

The legal requirements for medical records are evolving, exemplified by the upcoming Health Information Bill[12] and guidelines on the appropriate use and access of NEHR. These guidelines emphasise the importance of accurate, clear and contemporaneous medical records, which may be accessed and used appropriately by other healthcare professionals for clinical care purposes. Other important legal requirements are provided by the Computer Misuse Act and Personal Data Protection Act.

Since 2023, the MOH Workgroup for Drafting Guidelines for Appropriate Use and Access to NEHR has discussed the ethical and legal concerns surrounding the broader use of this national patient information database, which will be mandated by the future Health Information Act. In July 2024, the Workgroup issued a draft of the NEHR guidelines,[13] which provide comprehensive guiding principles on the contribution, access and use of medical records in NEHR.

Contribution

Healthcare professionals should make accurate, clear and contemporaneous medical records within their EMRs, considering that the health information extracted from these records may also be viewed on NEHR and used for clinical care purposes by other healthcare professionals. Any errors made should be amended as soon as reasonably possible.

Access

All information in NEHR should be treated with the same degree of confidentiality as all other medical records. Healthcare professionals should only access NEHR when they have been granted access for patient care purposes and should abide by any regulations or directives issued by the MOH regarding the authorised purposes for accessing NEHR.

Use

Healthcare professionals should consider whether they have sufficient information about their patients that is derived from history taking, clinical examination and relevant investigations before deciding if NEHR should be used. They should also review the NEHR information accessed before relying on it for clinical use. If incidental findings are discovered, healthcare professionals should use their judgement to decide whether any follow-up is required. Healthcare professionals should use their judgement to decide if there is a need to access sensitive health information. If they do access sensitive health information, they should handle the information with care.

Some organisations may approve the access and use of patients’ data for audits, education and research. For NEHR, it is clear that the user should only access and use the patient’s information when the patient is under the user’s direct care — typically during consultation. Any access and use of patient information before or after consultation requires a good justification, such as triaging the patient’s referral, pre-clerking and follow-up for laboratory results. Proper documentation of out-of-consultation access and use of NEHR information is recommended, as all NEHR access is subject to audit. NEHR data cannot be used for education, audit, research, insurance or employment purposes unless approved by the Ministry of Health.

PERSPECTIVES AND NARRATIVES

It is vital to document both the patient’s and doctor’s views and perspectives, in addition to clinical findings and decisions. This helps one understand the consultation process retrospectively, especially in cases of complaints and litigation. To humanise the medical records, it is advisable to document the patient’s or family’s personal facts, concerns, questions and responses to the doctor’s recommendations.[14] In addition, the doctor’s clinical reasoning, factors considered when offering or declining a treatment option, and plans for monitoring potential complications or side effects should be documented.

CONCLUSION

Medical records and documentation are integral to the medical profession. Keeping good medical records is crucial for daily clinical work, professionalism, ethics and achieving the goals of medicine. The transition to EHRs and national-level systems such as NEHR introduces additional considerations for handling medical records. Adhering to guidelines and maintaining clear, accurate and contemporaneous documentation are essential for accountability and optimal patient care.

KEY LEARNING POINTS

1. Medical documentation starts on the first day of a medical career and is a key aspect of professionalism.

2. Maintaining good medical records reflects professionalism, ethics and accountability, while facilitating continuity of care and resolution of conflicts.

3. The ECEG and Handbook of Medical Ethics delineate the essential principles for keeping clear, accurate and contemporaneous medical records.

4. The transition to EHRs and NEHR raises concerns about the handling of medical records. The Computer Misuse Act, Personal Data Protection Act, hospital/clinic policies and upcoming NEHR guidelines provide key guidance on their use and access.

5. The NEHR guidelines specifically address the contribution, access and use of medical records.

Closing Vignette

When a doctor uses the hospital’s or clinic’s computer system to access any patient’s data, he/she has to observe the policies and rules set by the organisation (hospital clusters, private hospitals, clinic groups, etc.). The patient information belongs to the organisation, which needs to comply with the Personal Data Protection Act. Therefore, Doctor B cannot access the hospital system to obtain information of someone not under his direct care. As his wife is not his patient, such access to the hospital system would breach the hospital policies and rules.

Conflicts of interest

There are no conflicts of interest.

SMC CATEGORY 3B CME PROGRAMME

Online Quiz: https://www.sma.org.sg/cme-programme

Deadline for submission: 6 pm, 29 October 2025

Question: Answer True or False
1. Regarding the role of good medical records in healthcare ethics:
(a) It is a practice rooted in professionalism and ethics.
(b) It benefits patients by ensuring accurate and contemporaneous documentation.
(c) It is unhelpful for professional accountability.
(d) It enriches clinical education and research.
2. Regarding maintaining of good medical records:
(a) Accurate and detailed medical records allow healthcare professionals to make informed decisions based on a patient’s past and present health status.
(b) Good medical records are important when patients see multiple specialists or transit between different healthcare settings.
(c) Maintaining accurate and contemporaneous medical records neither prevents liability nor assures defence support for healthcare professionals in legal proceedings.
(d) Detailed medical records contribute to the body of medical knowledge and support the development of evidence-based practices.
3. Regarding access to patient information based on the draft Guidelines on the Appropriate Use and Access to National Electronic Health Record (NEHR; July 2024):
(a) All information in NEHR should be treated with the same degree of confidentiality as all other medical records.
(b) Patient information in NEHR can be accessed for education, audit and research.
(c) Healthcare professionals should only access NEHR when they have been granted access for patient care purposes.
(d) Healthcare professionals can access NEHR for their family’s medical information.
4. Regarding use of patient information based on the draft Guidelines on the Appropriate Use and Access to NEHR (July 2024):
(a) Healthcare professionals do not need to exercise their clinical judgement to determine if they have sufficient information before deciding to use NEHR.
(b) Healthcare professionals should review the NEHR information accessed before relying on it for clinical use.
(c) If incidental findings are discovered, healthcare professionals do not need to decide whether any follow-up is required.
(d) Healthcare professionals should use their judgement to decide if there is a need to access sensitive health information.
5. Regarding documentation of the patient’s and healthcare professional’s views and perspectives in medical records:
(a) It does not help in understanding the consultation process retrospectively.
(b) It is crucial in understanding the actual clinical discussion in cases of future complaints and litigations.
(c) The patient’s concern, questions and responses to the doctor’s recommendation reflect their belief, value, emotion and priority.
(d) The healthcare professional’s clinical reasoning and considerations in offering or declining a treatment option reflect their logic behind aligning with or deviating from conventional treatment.

Funding Statement

Nil.