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What makes good clinical records?

01 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 Singapore Medical Council.

The SMC [1] cites the following requirements for medical notes:

  1. Medical records kept by doctors shall be clear, accurate, legible and shall be made at the time that a consultation takes place, or not long afterwards.

  2. Medical records shall be of sufficient detail so that any other doctor reading them would be able to take over the management of a case. All clinical details, investigation results, discussion of treatment options, informed consents and treatment by drugs or procedures should be documented.

Good clinical records will be well executed in terms of both content and presentation. You may wish to consider the following information regarding content and presentation when preparing medical records for your patients.

Content

  • 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 – details of the patient’s capacity to consent (or lack of) and their consent to proposed investigations, treatments or procedures. Details also of all treatment options discussed (including not receiving 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.

Presentation

  • 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.

References

  1. SMC Ethical Code and Ethical Guidelines p7

Further reading