Record keeping

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. 

Survival tips

• 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.
• 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 habitual.
• Document 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 – eg, 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 under The Data Protection Act 1998.

Scenario

Dr P is working in a medical ward when she sees Mrs G, a patient referred from A&E, after she suddenly collapsed. She takes a comprehensive history, and does a complete examination. Dr P then notices that some blood samples were taken from her in A&E, and checks on the results server on the hospital intranet. She finds out that the samples “have clotted” and new samples need to be sent.

The nurses are quite busy, but they agree that they’ll do it as soon as possible. Dr P finishes her shift by writing the history, examination findings and results, she also writes “bloods”, followed by a tick, meaning that they have been sent. During the handover she doesn’t tell the next doctor that the blood results need checking.

Mrs G becomes unwell within the next few hours, and the ST2 doctor on duty comes to see her. He is reassured by the notes that recent blood results were normal, and checks on the results server himself. It is only at this stage, that it is discovered that the patient is severely anaemic. Dr P failed to ensure that the documentation was clear indicating what had, and what had not been done. Luckily Mrs G came to no harm.