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The apprentice - Dr John Paul Campion

“If there is not time to take notes, there is not for GPs and patients time to see patients properly, and something is at fault either with the method or the means.” Dr John Paul Campion, a GP registrar from Mid Leinster, considers the importance of keeping good medical records

I often wonder just how good my record keeping is. I understand that as a GP registrar I will inevitably keep longer notes than some of my senior colleagues. Of course, just because they are longer does not mean that they are necessarily better.

It’s only when you are forced to review your notes after the consultation that you sometimes realise just what you have written. I keep contemporaneous notes on the computer. I type as I talk to the patients and I paraphrase as much as possible how they describe their reason for presentation. At the end I summarise with my impressions and plan going forward. I have always assumed that my notes read as I would have expected the consultation to have gone. I keep notes in this way to provide efficiency. It allows me to move quickly on to the next patient and to feel comfortable in what I have written.

I keep contemporaneous notes on the computer. I type as I talk to the patients and I paraphrase as much as possible how they describe their reason for presentation

Recently, I had reason to review the notes of a deceased patient. An unexpected death, I read over multiple consultations I’d had with him over the previous nine months. I was surprised at how broken my notes read – instead of flowing as I thought they would, they were more a collection of statements than a true narrative of the consultations.

If the point of note taking is to ensure that future readers can have a fuller understanding of the consultation, then perhaps a better way of recording notes is required. If I find it difficult to follow the flow of a consultation from my own notes, then surely someone else would find far more difficulty in doing so.

An unnamed correspondent to the British Medical Journal in March 1921 wrote: “If there is not time to take notes, there is not time to see patients properly, and something is at fault either with the method or the means.” This message rings true almost 100 years later. If an outsider is reviewing your records you must assume that if they find your note keeping to be too short, incomplete or incomprehensible, then they might find the consultation to be equally so, and may make inferences from this. I suppose the message is that just assuming that the notes you have kept are perfect is probably not enough.

Regular review on a random basis will help you to identify deficiencies in your records. Self assessment and criticism can help prevent unnecessary problems in the future when others request to review your notes. Using this review you can adapt your style to better suit your needs and better serve your practice.

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