Writing good medical records

Medical notes should allow another medical professional to reconstruct your consultations with the patient. You may be required to give an explanation under the Data Protection Act (1998) if the information contained in the records is not intelligible.

Include any uncertainties about diagnosis, and steps taken to rule these out

Notes should include:

• History – relevant to the condition, including any answers to direct questions.
• Examination of the patient – any important findings, both positive and negative, and details of any objective measurements, such as blood pressure.
• Diagnosis – how you arrived at this conclusion. Include any uncertainties about diagnosis, and steps taken to rule these out. Detail any further investigations you have arranged.
• Information – what you have told the patient, including any details of the risks and benefits of particular treatments.
• Consent – details of any consent the patient has given, together with the background of any discussion that led up to that consent.
• Treatment – detail the type and dosage of drugs, the total amount prescribed and any other treatment you have organised.
• Follow-up – include the arrangements for following up tests, future appointments and any referrals made.

Presentation is key

You should ensure that records are:

• If you can’t write legibly, type your notes or have them typed

  Clear – For written notes, write legibly in black ink. If you can’t write legibly, type your notes or have them typed. Sign each entry with a date and time.
• Objective – opinions should be based on the facts you have recorded. Remember that patients or their relatives are likely to read the notes you write.
• Contemporary – write notes up as soon as possible after an event.
• First-hand – if information has been given to you by anyone but the patient, record that person’s name and position, eg, a relative, friend, translator, ambulance staff or the police.
• Tamper-proof – any attempt to amend records should be immediately apparent, eg, notes should always be written in pen, not pencil. Computer systems should record the date and author of any notes, and track any amendments.
• Original – implied by the last point, medical records should not be altered, or amended without suitable annotation.

Watch out for abbreviations

Using abbreviations saves time, but can lead to problems. Abbreviations should be unambiguous and universally understood. This is particularly true in general practice, where a patient may have unrelated conditions with shared abbreviations. Certain abbreviations are unacceptable, such as coded expressions of sarcasm, or humorous abbreviations to describe a patient’s condition.

Tips when starting at a new practice

Many practices will provide you with an induction pack or arrange an induction day, which will, among other things, cover how records are organised. Finding out the answers to the following questions will help make your first days in the practice run smoothly.

• Computer records – How does the system work? How are usernames and passwords arranged? How often are they changed?
• Paper records – How are records filed? How are records signed in and out? How are they kept secure?
• Abbreviations – What abbreviations are acceptable and commonly used (eg, other members of staff, local clinics and hospitals)?
• Tests – How are they ordered and how is this noted in the records? How are late tests followed up? Is there a tracker system?
• Results – How do they come back? How will you be notified that results need to be reviewed? How are the results filed?