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 abbreviation as it may lead 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.
- 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)
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