Medical record keeping: be clear, accurate, and timely
Medical records are a fundamental part of a doctor’s duties in providing patient care.
As well as handwritten clinical notes, medical records include emails, scanned records, consent forms, text messages, verbal correspondence between health professionals, laboratory results, x ray films, photographs, video and audio recording, and any printouts from monitoring equipment.
The records form a permanent account of a patient’s illness. Their clarity and accuracy is paramount for effective communication between healthcare professionals and patients.
Information in medical records should be documented on a daily basis and in chronological order demonstrating continuity of care and response to treatment. The information should be comprehensive enough to allow a colleague to carry on where you left off.
Low priority
Despite this importance, medical record keeping is often given a low priority. Notes are often poorly maintained and sometimes patient notes are not readily available.
It is common to find illegible entries, offensive comments, and missing information, and there is often inconsistency between entries by doctors, nurses, and midwives.
Editing medical records is evidence that they are inaccurate and makes them impossible to defend. The General Medical Council clearly states that records should be made at the time the events happen, or as soon as possible afterwards.
Poor record keeping is a major factor in litigation cases brought against healthcare professionals.
No standard model
In 2004, Beverley Scott of the NHS Information Standards Board established that there is a lack of a standard model across the NHS for documenting and communicating information.
To achieve good medical practice, health professionals must keep up to date with legal requirements and record keeping; professional bodies should outline what they expect from their members; and organisations should have standardised procedures for recording and communicating information.
7 top tips for good medical record keeping
- Write legibly; sign legibly – with your name, rank and number (how will the next person know how to contact you?)
- Include details – of the patient, date, and time
- Record them soon after a patient contact, preferably now
- Avoid abbreviations
- Do not alter an entry or disguise an addition
- Check dictated letters – and don’t copy to people unnecessarily (it will reduce their focus in more important information)
- Data Protection Act 2018 – be familiar with it. Everyone responsible for using personal data has to follow strict rules called ‘data protection principles’.
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