Common problems
All of the following can compromise patient safety or lead to medicolegal problems:
- Not recording negative findings
- Not recording substance of discussions about the risks and benefits of proposed treatments
- Not recording drug allergies or adverse reactions
- Not recording the results of investigations and tests
- Illegible entries
- Not reading the notes when seeing a patient
- Making derogatory comments
- Altering notes after the event
- Wrong patient/wrong notes.
Before the healthcare professional makes an entry in the patient’s healthcare record, s/he shall establish that the record belongs to the patient being attended
Box 4: HSE guidance on identifying patients
3.3.1 The service user¹s name is on each side of each page where service user information is documented and each side of each page has the correct unique service user identification number and/or identification label. This requirement also applies to every screen on computerised systems.
3.3.2 Where appropriate, before the healthcare professional makes an entry in the service user¹s healthcare record, s/he establishes that the record belongs to the service user being attended.
3.3.3 This is done by verifying name and date of birth with the service user and for in-patients/day-cases by cross-referencing the service user¹s identification band with the healthcare record.
National Hospitals Office, Standards and Recommended Practices for Healthcare Records Management (2011).