Good medical records – whether electronic or handwritten – are essential for the continuity of care of your patients. For health professionals, good medical records are vital for defending a complaint or clinical negligence claim; they provide a window on the clinical judgment being exercised at the time. The presence of a complete, up-to-date and accurate medical record can make all the difference to the outcome.
Here are a few tips to help you with your record keeping:
Always date and sign your notes: Whether written or on computer. Don’t change them. If you realise later that they are factually inaccurate, add an amendment.
Corrections must be stated: Any correction must be clearly shown as an alteration, complete with the date the amendment was made, and your name.
Making good notes should become routine.
Document all decisions made: Any discussions, information given, relevant history, clinical findings, patient progress, investigations, results, consent and referrals.
Medical records can contain a wide range of material: Such as handwritten notes, computerised records, correspondence between health professionals, lab reports, imaging records, photographs, video and other recordings and printouts from monitoring equipment.
Do not write offensive or gratuitous comments: E.g. racist, sexist or ageist remarks. Only include things that are relevant to the health record.
Patients have a right to access their own medical records.
Risks can never be eradicated: Good record-keeping helps to maintain best practice, aiding clear communication between professionals, and demonstrates that best practice has been followed.
Organise your records: Complete, contemporaneous and well-organised medical records are essential for good medical practice and continuity of care. They are necessary for a healthcare professional’s defence against a claim or complaint and can be seen to reflect the quality of care provided.
Appropriate record-keeping is recognised as an important component of professional standards.