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Part 1: Quality and accessibility

Quality

Adequate medical records enable you or somebody else to reconstruct the essential parts of each patient contact without reference to memory. They should therefore be comprehensive enough to allow a colleague to carry on where you left off.

Poor-quality medical records are not only a major cause of iatrogenic injuries, they also make it difficult to defend a clinical negligence claim or an HPCSA disciplinary inquiry; it is axiomatic that poor note-keeping is evidence of poor clinical practice. The common problems listed in Box 1 are all-too-frequent re-occurring themes in MPS case files.

Good medical records can be characterised as:

  • Comprehensive
  • Contemporaneous
  • Comprehensible and accurate
  • Attributable.

Box 1: Common problems

Any of the following may compromise patient safety or lead to medicolegal problems:

  • Not recording negative findings
  • Not recording the substance of discussions about the risks and benefits of proposed treatments, including no treatment
  • Not recording drug allergies or adverse reactions
  • Not recording the results of investigations and tests
  • Illegible, unsigned or undated entries
  • Not consulting the relevant records when seeing a patient
  • Making derogatory comments
  • Altering notes after the event
  • Wrong patient/wrong notes.