Top ten tips for record keeping

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. Notes are a reflection of the quality of care given so get into the habit of writing comprehensive and contemporaneous notes.

1. 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.
2. Any correction must be clearly shown as an alteration, complete with the date the amendment was made, and your name.
3. Making good notes should become habitual.
4. Document decisions made, any discussions, information given, relevant history, clinical findings, patient progress, investigations, results, consent and referrals.
5. 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.
6. Do not write offensive or gratuitous comments – eg, racist, sexist or ageist remarks. Only include things that are relevant to the health record.
7. Patients have a right to access their own medical records under The Data Protection Act.
8. Risks can never be eradicated, even with best practice, only reduced. Good record keeping helps to maintain best practice, aiding clear communication between professionals, and demonstrates that best practice has been followed.
9. Complete, contemporaneous and well organised medical records are essential for good medical practice and continuity of care. They are necessary for a healthcare professional’s defence against a claim or complaint and can be seen to reflect the quality of care provided.
10. Appropriate record keeping is recognised as an important component of professional standards.

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• Read our guide on good medical records guide on good medical records