Membership information 1 800 81 5837
Medicolegal advice 1 800 81 5837

What makes good clinical records?

29 September 2016

Medical records  whether handwritten or electronic  are essential to allow continuity of care for your patients. Good record keeping means you or a colleague can reconstruct the key parts of each patient contact without relying on memory.

Good clinical records are important in delivering high quality healthcare, particularly when a number of different clinicians are involved in patient care at the same time. Unless everyone involved in clinical management has access to the information they require, duplication of work, delays and mistakes are inevitable.

Clear and detailed records are also important in providing a factual base necessary for responding to complaints and claims, and for production of legal reports. A lack of clear documentation can make defence of a claim, for example, very difficult. Poor record keeping could also attract criticism by the Medical Council.

The Medical Council of Malaysia [1] lists the requirements of clinical records as the following:

A medical record is documented information about the health of an identifiable individual recorded by a practitioner or other healthcare professional, either personally or at his or her instructions. It should contain sufficient information to identify the patient, support the diagnosis based on history, physical examination and investigations, justify the professional management given, record the course and results thereof, and ensure the continuity of care provided by practitioners and other healthcare workers to that particular patient.

Good clinical records will be well executed in terms of both content and presentation. You may wish to consider the following information regarding:

  • Relevant medical history
  • Examination and other relevant clinical findings - Include important positives and negatives and details of objective measurements such as blood pressure
  • Differential diagnosis
  • Investigations - Details of any investigations requested.
  • Treatment - Details of drugs, doses, amount prescribed, and any other treatment organised (include the batch number and expiry date of any medications personally administered).
  • Capacity and Consent - All treatment options discussed, including the option of no treatment, the benefits and risks of each option and any questions that were asked by the patient.
  • Referrals and follow-up - Arrangements that have been made for follow-up tests, future appointments and referrals. Include any ‘safety-netting’ advice given to the patient about when to seek more urgent review.
  • Clearly written - good clinical records will be understandable when handwritten. Each entry should also be legibly signed with the date and time.
  • Objective - it is important that clinical records are factual and free of subjective opinion about patients or their relatives. You should always assume that patients will read their notes at some point.
  • Contemporaneous - you should write up clinical records as soon as possible after the consultation in order to ensure accuracy and clarity.
  • Attributable - if any information has been given to you by anyone other than the patient, you should record who has provided this, as well as what they said.
  • Original - notes should not be retrospectively amended without making clear when the amendments have been made and why. In the event that you have made a factual error, do not obliterate the entry that you wish to correct. Instead, run a single line through it so it can still be read and add the correction including the date and your signature. Failure to do so could lead to allegations of dishonesty, attempting to pass amendments off as part of the original record. Amendments to electronic records can be tracked by audit trail and should be clearly marked on the file.
  • Easy to understand - avoid the use of abbreviations, as unconventional or unfamiliar abbreviations could lead to confusion amongst staff and untoward incidents.

[1] Medical records and medical reports, Guideline of the Malaysian Medical Council MMC Guideline 002/2006 p6