Medical documentation should authentically represent every consultation and is primarily intended to support patient care. Good record-keeping means you or a colleague can reconstruct key parts of each patient contact without relying on memory.  In an event of a complaint or clinical negligence claim, evidence in the clinical records will be largely considered.

Key points for good record keeping:

• Clear, accurate, objective and legible documentation.
• Every page in the medical record should include the patient’s name, identification number (NHS number/hospital number) and location in the hospital.
• Every entry should be dated, timed using the 24-hour clock and signed by the person making the entry.
• Every medical record should identify the most senior healthcare professional present at the time of entry and the team present.
• Make records at the same time as the event you are recording or as soon as possible afterwards.
• If you have obtained information from another colleague, record who provided this information, their designation and what was stated.
• Avoid abbreviations as it may lead to confusion among staff.
• If you have to make an amendment to your notes, make sure it is clear why this was made. Do not obliterate the entry you wish to correct, instead run a single line through it so it can still be read. Make sure the correction has a date, time and signature.
• Sign your entry including a printed name against your signature and your designation.

Further reading and resources:

• GMC: Good Medical Practice.
• https://www.themdu.com/guidance-and-advice/guides/good-record-keeping
• https://www.medicalprotection.org/uk/articles/an-mps-essential-guide-to-medical-records
• Be familiar with the Data Protection Act 1998
• Your medical indemnity insurer will be able to provide you with more guidance if required

By Dr Lola Meghoma (FY2)