Presentation

If the records are unclear, inaccurate or written in such a way that they’re difficult to follow, the content might as well not be there

Content is important, but so is presentation. If the records are unclear, inaccurate or written in such a way that they’re difficult to follow, the content might as well not be there; worse than that, it could cause errors and misunderstandings. Good notes therefore have the following attributes:

• Clear – both legible and understandable when handwritten. Each entry should be legibly signed with the date and time.
• Objective – clinical records should be factual and free from subjective comments about patients or their relatives. Always assume that patients will read their clinical records at some stage.
• Contemporaneous – clinical records should be written up at the time to ensure accuracy.
• Attributable – if information has been given to you by someone other than the patient, then you should record who provided the information as well as what they said.
• Original – sometimes it is necessary to amend or alter medical records, for example if a factual error has been made. Any correction must be clearly shown as an alteration, complete with the date the amendment was made and the name of the person who made it so there can be no allegation that the alteration was an attempt to deceive anyone into thinking that it is part of the original record.