Would your healthcare records stand up to scrutiny?
Healthcare records are created primarily to support patient care. However, they may later be examined during a complaint, clinical incident review, regulatory investigation, Coroner’s inquest or court case.
At that point, the quality of the record matters.
A record should provide a clear, factual and timely account of the care provided, the decisions made and the information available at the time. Incomplete, unclear or inconsistent documentation can make it difficult to establish what happened and why.
Recent developments in Ireland also highlight growing expectations around access, data protection and healthcare information governance.
Almost 100,000 requests for HSE information
In May 2026, RTÉ reported that the HSE had received almost 100,000 legal requests for information over the previous three years. The majority came from patients trying to access their own medical records.
The report highlighted the practical difficulties patients can experience when records are fragmented across different services or remain in paper-based systems. It also reinforces the importance of maintaining records that are organised, accessible and capable of being understood by someone who was not directly involved in the care provided.
Data breaches are not limited to cyberattacks
The Data Protection Commission received 6,521 valid breach notifications during 2025. Almost half resulted from correspondence being sent to the wrong recipient.
These figures cover all sectors rather than healthcare alone. However, they are particularly relevant to healthcare organisations because medical information is sensitive personal data. A letter, report or record sent to the wrong person can have serious consequences for the patient and the organisation.
The figures show that information governance is not solely an IT responsibility. Everyday practices around creating, checking, sharing, storing and disposing of records also require attention.
Read the Data Protection Commission’s 2025 Annual Report highlights.
The cost of weak information governance
In June 2026, the Data Protection Commission fined the HSE €300,000 following an inquiry into a ransomware attack affecting the laboratory information system at Midlands Regional Hospital Tullamore.
Among its findings, the Data Protection Commission concluded that the HSE had failed to maintain a complete and compliant record of its processing activities at the time of the breach. It also identified failures relating to data security, third-party processing arrangements and information provided to affected patients.
The decision concerned organisational and technical controls rather than the quality of individual clinical notes. However, it demonstrates the wider importance of being able to show how healthcare information is created, processed, protected and managed.
Read the Data Protection Commission decision.
What should a healthcare records review examine?
A useful records review should look beyond whether a form has been completed. It should consider whether the record supports patient care, accountability and external scrutiny.
Questions to consider include the following.
- Are entries made promptly and in chronological order.
- Is it clear who created each entry and when it was made.
- Are facts, observations, professional opinions and information provided by others clearly distinguished.
- Does the record explain significant decisions and the reasons for them.
- Are corrections and later additions made transparently.
- Are consent and capacity decisions documented appropriately.
- Could another healthcare professional understand the patient’s care from the record.
- Are confidentiality, access and data protection requirements being followed.
- Could the professional responsible explain and stand over the record if questioned several months or years later.
These questions can help identify recurring risks across a team, department or organisation.
Download the free Healthcare Records Audit Checklist
La Touche Training has created a free Healthcare Records Audit Checklist to help healthcare professionals and organisations conduct a structured review of their current documentation practices.
The checklist covers the following areas.
- Timely, factual and clearly written records.
- Documentation standards that support continuity of care and professional accountability.
- Records that may be examined during complaints, investigations, inquests or regulatory proceedings.
- Data protection, confidentiality and patient-access considerations.
- Common documentation risks that managers should look for across teams or departments.
The checklist is suitable for healthcare managers, clinical governance leads, risk and quality teams, records officers and healthcare professionals responsible for clinical notes, care plans, consent records or incident documentation.
Download the free Healthcare Records Audit Checklist.
Develop your healthcare records and witness skills.
An audit can identify areas for improvement. Training can then help staff understand how to address those issues in practice.
La Touche Training is delivering the following online courses.
Effective Records, Reports and Witness Skills for Healthcare Professionals.
29 and 30 September | Online | Two days | €645
This practical two-day programme covers GDPR-compliant record keeping, professional report writing and witness skills.
Day one examines why clinical records are maintained, the standards expected of healthcare records and how records and reports may be used as evidence. Participants will also consider report structure, the distinction between fact, inference and opinion, and the source and weight of evidence.
Day two explains the process of giving evidence and the roles of the people involved. It also examines preparation, questioning techniques and how healthcare professionals can give clear, honest and objective evidence. Practical exercises and role-plays are included.
The course is delivered by qualified lawyers with healthcare litigation experience. Book the two-day course.
Book either day individually.
Participants who do not require the complete programme can book either day separately.
Day one: Effective Records, Reports and GDPR for Healthcare Professionals.
29 September | Online | €295
This course focuses on healthcare record keeping, GDPR requirements and the preparation of clear, factual and professional reports. Book day one.
Day two: Witness Skills for Healthcare Professionals.
30 September | Online | €395
This course prepares healthcare professionals to give evidence in court cases, Coroner’s inquests, fitness to practise hearings and employment proceedings. It includes practical guidance on preparation, legal procedures, supporting records and cross-examination. Book day two.
Healthcare Records on Trial
1 October | Online | One day | €295
This intensive one-day course examines the practical and legal implications of healthcare records for medical, health and social care professionals.
Participants will consider accountability, professional regulation, patient consent, GDPR, factual and opinion evidence, patient access to records, discovery and how healthcare records may be examined in legal proceedings.
The course will help participants produce professional records that support patient care and enhance their credibility if they are required to give evidence. Book Healthcare Records on Trial.
Take the first step
Start by reviewing a sample of your organisation’s healthcare records using the free audit checklist.
Where the review identifies gaps or inconsistent practices, consider whether staff need clearer procedures, further guidance or practical training.
Download the Healthcare Records Audit Checklist or view La Touche Training’s healthcare courses.
