Record keeping
Record keeping
Time to read article: 2 mins
Legible notes must be kept primarily to assist the patient when receiving treatment. But, secondly, should there be any future litigation against your hospital the notes will form the basis of the hospital’s defence. Notes are a reflection of the quality of care given so get into the habit of writing comprehensive and contemporaneous notes.
Read more
Articles and features
24/12/2016
The healing power of saying “sorry” in healthcare
The healing power of saying “sorry” in healthcare
Time to read article: 2 mins
If I accidentally bump into someone and hurt them walking along the street, my immediate reaction is to say sorry, regardless of whether it was or wasn’t my fault. What happens when we place a similar analogy into a doctor/patient context?
Read more
Articles and features
17/10/2016
'Dr Google' in the patient chair
'Dr Google' in the patient chair
Time to read article: 2 mins
There is no escaping the fact that ‘Dr Google’ is becoming more and more influential in GP consultations. At Medical Protection, we commissioned a YouGov online survey of 2021 British adults to look at the pros and cons of seeking medical advice from the internet.
Read more
For the record…
For the record…
Time to read article: 3 mins
The importance of good, clear and thorough medical records cannot be underestimated - not only do they ensure the smooth running of your day-to-day life in practice; they might prove invaluable in the event of a claim.
Read more
Medical records - Northern Ireland
Time to read article: 3 mins
Good medical records – whether electronic or handwritten – are essential for the continuity of care of your patients. Adequate medical records enable you or somebody else to reconstruct the essential parts of each patient contact without reference to memory. They should therefore be comprehensive enough to allow a colleague to carry on where you left off.
Read more
Top ten tips for record keeping
Time to read article: 1 mins
Good medical records – whether electronic or handwritten – are essential for the continuity of care of your patients. The notes will also form the basis of the hospital’s defence should there be any future litigation against your hospital.
Read more
Medical records - Scotland
Time to read article: 3 mins
Good medical records – whether electronic or handwritten – are essential for the continuity of care of your patients. Adequate medical records enable you or somebody else to reconstruct the essential parts of each patient contact without reference to memory. They should therefore be comprehensive enough to allow a colleague to carry on where you left off.
Read more
Cumulative errors
Time to read article: 3 mins
Mrs G, 34, presented to the delivery suite at 12pm, 38 weeks into her first pregnancy. Her antenatal care had been uneventful apart from measuring slightly “large for dates”. She was found to have a longitudinal lie with a cephalic presentation, and was experiencing three contractions every ten minutes. The midwife examined her and found her to be 2cm dilated with a fully effaced cervix and “intact membranes”.
Read more
Needlestick injuries - Scotland
Time to read article: 3 mins
Needlestick injuries can be classified as any piercing wound caused by a hypodermic needle, or by other sharp instruments or objects such as scalpels, mounted needles, broken glassware, etc. This factsheet sets out the main concerns for healthcare professionals and what to do when needlestick injuries happen.
Read more