If you write anything in a patient’s records, the HPCSA says that you must sign it and write your name in block capitals.1 You should also record the date and time and, in the case of hospital records, your bleep or phone number.
A common cause of adverse incidents is lack of access to critical information. This may be because the atient’s records were not available at the time, or (more commonly) because the needed information was lost in voluminous casenotes.
Medical records nowadays include a wide variety of documents generated on – or on behalf of – all the health professionals involved in patient care. Any communication related to a patient’s clinical condition and care belongs in the healthcare record.
Given the amount of information contained in the average medical record, it is important not only to file information chronologically in the correct section of the case notes, but to extract and highlight any crucial information, such as allergies, sickle-cell status, special drug needs, etc on the summary sheet and/or the cover. Record significant results of tests and investigations in the progress notes and pass on verbally and in writing any significant or critical information when handing over patient care to a colleague.
When writing up your notes, try to organise the information systematically and use headings, etc to make it easier both for you and your colleagues to quickly pick out relevant information. The POMR-SOAP system, though not ideal, has the advantage of imposing a logical, easy-to-follow structure to the medical record. A problem list acts as a quick guide to clinicians seeing a patient for the first time (see Box 4).
If you are hand writing notes, be careful to write legibly and in non-erasable ink. Indecipherable scrawlings are no use to your colleagues. At best, they are valueless if they cannot be understood; at worst, they can be misinterpreted, resulting in avoidable harm to patients. There have been numerous adverse incidents caused purely by mis-read orders and prescriptions, for example.
Box 4: POMR and SOAP
The basic components of the POMR(Problem Oriented Medical Record) are:
- Data Base – History, Physical Exam and Laboratory Data
- Complete Problem List
- Initial Plans
- Daily Progress Note
- Final Progress Note or Discharge Summary.
Steps 1, 2 and 3 are completed by the admitting physician.
Each problem on the problem list is numbered. The problem list is placed at the front of the case notes.
Daily Progress Notes (step 4) are made on separate pages for each condition on the problem list using SOAP:
Subjective – what the patient says
Objective – what you detect – examination and test results
Assessment – your conclusions
Problem list & Plan – management and follow up.