What makes good clinical records?

Content

Good clinical records will contain all the information one clinician needs to take over where another left off – or, to put it another way, to allow a clinician to reconstruct a consultation or patient contact without relying on memory. This will include:

Many follow-up consultations will be with different members of the team, who will be totally reliant on the clinical records and therefore will need as much information as possible

  • History – relevant to the condition including any positive and negative answers to direct questions
  • Examination of the patient
  • All systems examined
  • All important findings, both positive and negative, with details of any objective measurement such as blood pressure, peak flow, etc
  • Differential diagnosis
  • Investigations – details of any investigations arranged
  • Referral – details of any referral made
  • Information – information given to the patient concerning risks and benefits of proposed treatments
  • Consent – details of consent given to proposed investigations, treatments or procedures
  • Treatment – details of the main doses of drugs, total amount prescribed, any other treatment organised with batch number and expiry date of any medications personally administered
  • Follow-up – arrangements for follow-up tests, future appointments and referrals made
  • Progress – any further consultations, how the patient’s condition has progressed.

That may seem like a daunting list, but it is all important information that someone would have to remember if it is not recorded – and both doctors’ and patients’ memories are fallible. Many follow-up consultations will be with different members of the team, who will be totally reliant on the clinical records and therefore will need as much information as possible.

The mnemonic SOAP (below) is a useful reminder of the essential content you should include.

Box 1: Essential content (SOAP)

  • Subjective – what the patient says
  • Objective – what you detect – examination and test results
  • Assessment – your conclusions – often the differential diagnosis
  • Problem list & Plan – management and follow up

  

Case 2

A 26-year-old single woman went to see her GP complaining of blackouts. He referred her to a neurologist, giving a detailed account of the blackouts but not disclosing the medication she was on, which included the oral contraceptive pill. The neurologist started the patient on anticonvulsants. Three months later she conceived. Her claim against both doctors succeeded. As the GP had failed to alert the neurologist to the fact the patient was taking the oral contraceptive pill, and the neurologist had not asked about medication, both had been in breach of their duty of care, causing the unwanted pregnancy.

  

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