What makes a comprehensive medical record? A good place to start is the HPCSA’s Guidelines on the Keeping of Patient Records (Booklet 14).
Recording an “assessment of the patient’s condition” might seem straightforward. Yet often, when patient records are examined in response to a clinical negligence claim, this detail is interpreted in many different ways. Interpretations vary from detailed notes on history, examination and diagnosis, to just the noting of a diagnosis, eg, “tension headache”.
The latter version is not of much help if a doctor needs to defend him/herself against a complaint of negligence for missing a slow growing meningioma. On the one hand is the need to write concise notes to save time, whilst on the other hand, doctors need to be able to justify their clinical actions and diagnoses, which necessitates more elaborate note keeping.
When defending doctors against negligence claims, it is very valuable if notes reflect findings that influenced diagnostic and management decisions. These findings do not have to be described in detail. A comment of “no meningial irritation/ no ↑ cranial pressure” in the notes of a patient with headache is helpful in illustrating that due consideration was given to so called “red flag” conditions at the time of consultation.
Problems can also arise with information that is noted, but gets “lost” within the patient file
If patients were given information on their condition, or possible danger signs, a note “advised on condition” is very helpful in defending against the complaint of a patient that s/he was not informed. The use of written leaflets is even more valuable.
Problems can also arise with information that is noted, but gets “lost” within the patient file. An example of this is the note of “blood tests taken”, which can easily be overlooked. Although all practices should have a system by which new results are evaluated as they are received this is not always fail proof.
A useful tip, as a backup, is to write all special investigations requested in a contrasting colour ink such as red ink, or to use highlighters. This is very easily seen when paging through a file before a consultation. The doctor can then ensure that tests are appropriately reacted on during the consultation.
Correcting an error as described by the above guidelines is specific to paper records: an error or incorrect entry discovered in the record may be corrected by placing a line through it with ink and correcting it. The date of change must be entered and the correction must be signed in full. The original record must remain intact and fully legible. Additional entries added at a later date must be dated and signed in full. The reason for an amendment or error should also be specified on the record.
When considering electronic patient records, the HPCSA instructions on retention of records on CD-ROM gives some indication of principles to follow: electronic records need to be captured in a format that permits once only writing, so that old information cannot be overwritten, but new information can be added. Previous notes kept in the rooms must be in read-only format. A backup copy must be kept and stored in a physically different site in order that two discs/sources can be compared in the case of suspicion of tampering.
What not to write is as important as what to write
What not to write is as important as what to write. Disparaging comments indicating the doctor’s irritation or dislike of a patient must never be reflected in a patient’s notes. Remember, notes may be read in open court.
Medical records should include:
- Personal (identifying) particulars
- Bio-psychosocial history of the patient, including allergies and idiosyncrasies
- Time, date and place of every consultation
- Assessment of the patient’s condition
- Proposed clinical management of the patient
- Medication and dosage prescribed
- Patient’s reaction to treatment or medication, including adverse effects
- Test results
- Imaging investigation results
- Information on the times that the patient was booked off from work and the relevant reasons
- Written proof of informed consent, where applicable.