For the sake of good continuity of care, patients’ records should be kept as up to date as possible, which means that information should be added to the patient’s notes as soon as it becomes available. It is good practice to make a habit of noting information as it arises so that it is not lost if something happens to distract your attention – eg, an emergency, a phone call, or an interruption by a colleague.
Late entries and addenda
If you are making an entry in a patient’s records after an event, do not back-date it; you should clearly mark it as a “late entry” using the date and time at which the entry is actually made, and referring back to the date and time of the event the notes are about. Include the reason why the entry is being made retrospectively.
Any attempt to pass off a late entry as a contemporaneous note could, if discovered, attract serious criticism, including a finding of unprofessional conduct by the HPCSA or censure by the courts. Do not be tempted, if you find yourself facing allegations of negligence, to augment or alter the original contemporaneous notes. This not only amounts to unethical conduct, but will almost certainly make your case difficult to defend. If the plaintiff’s solicitors suspect that you have retrospectively altered the records, they can generally find proof of it by employing forensic experts to examine the ink and paper or by examining the audit trail of computerised records.
If you need to add further information relating to a specific situation or event that was recorded in the notes earlier, include it as an addendum. Enter the current date and time and write “Addendum to entry made on [date and time]”, followed by the reason for adding an addendum and the information you wish to add.