What makes good clinical records?

Content

Good clinical records will contain all the information one clinician needs to take over where another left off – or, to put it another way, to allow a clinician to reconstruct a consultation or patient contact without relying on memory. This will include:

• History – relevant to the condition including any positive and negative answers to direct questions
• Examination of the patient
• All systems examined
• All important findings, both positive and negative, with details of any objective measurement such as blood pressure, peak flow, etc
• Differential diagnosis
• Investigations – details of any investigations arranged
• Referral – details of any referral made
• Information – information given to the patient concerning risks and benefits of proposed treatments
• Consent – details of consent given to proposed investigations, treatments or procedures
• Treatment – details of the main doses of drugs, total amount prescribed, any other treatment organised with batch number and expiry date of any medications personally administered
• Follow-up – arrangements for follow-up tests, future appointments and referrals made
• Progress – any further consultations, the patient’s current condition, side effects, complications, etc.

That may seem like a daunting list, but it is all important information that someone would have to remember if it is not recorded – and both doctors’ and patients’ memories are fallible. Many follow-up consultations will be with different members of the team, who will be totally reliant on the clinical records and therefore will need as much information as possible. The mnemonic SOAP is a useful reminder of the essential content you should include.

As the GP had failed to alert the neurologist to the fact the patient was taking the oral contraceptive pill, and the neurologist had not asked about medication, both had been in breach of their duty of care, leading to the unwanted pregnancy.

Presentation

Content is important, but so is presentation. If the records are unclear, inaccurate or written in such a way that they’re difficult to follow, the content might as well not be there; worse than that, it could cause errors and misunderstandings. Good notes therefore have the following attributes:

• Clear – both legible and understandable when handwritten. Each entry should be legibly signed with the date and time.
• Objective – clinical records should be factual and free from subjective comments about patients or their relatives. Always assume that patients will read their clinical records at some stage.
• Contemporaneous – clinical records should be written up at the time of, or as soon as possible after, an event to ensure accuracy. Retrospective entries should be clearly dated, timed and signed, together with an explanation of why it is being written retrospectively.
• Attributable – if information has been given to you by someone other than the patient, then you should record who provided the information as well as what they said.
• Original – sometimes it is necessary to amend or alter medical records, for example if a factual error has been made. Any correction must be clearly shown as an alteration, complete with the date the amendment was made and the name of the person who made it so there can be no allegation that the alteration was an attempt to deceive anyone into thinking that it is part of the original record. (See Box 2.)

Abbreviations

Abbreviations are commonly used in clinical records but can be misinterpreted and lead to mistakes in diagnosis or management. So the rule is, when in doubt, write it out – in full. (See Box 3 for the rules on abbreviations that apply in national hospitals.)