The Importance of Keeping Good Medical Records
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.