When making notes in a patient’s records, a balance must be struck between brevity and comprehensibility. Generally speaking, the briefer the note, the more open to misinterpretation it will be.
On the other hand, no-one in a busy clinical setting has the time either to write or to read lengthy prose, so your notes should be as precise and concise as you can make them. Avoid generalisations and speculation. Stick to the facts and your objective findings. If you are reporting hearsay (eg, a relative’s account), use quotation marks and identify the source. Avoid using abbreviations that may not be understood in the context of multidisciplinary care.
It’s an obvious point to make, but errors in medical records can have a devastating effect on patients. Something as simple as a misplaced decimal point, hearsay presented as fact or test results filed in the wrong patient’s records can be fatally misleading. There are many reasons for inaccuracies in medical records – all of which are commonplace occurrences – such as being in a hurry, getting distracted, momentary inattention, or not fully understanding what someone is saying.
Consequently, it is very easy for inaccuracies to creep into the records; common causes are: not listening attentively when taking a patient’s history; relying on memory after an interruption; hasty writing that’s illegible; or not checking the identity of the patient before filing reports or writing a note.
There should, therefore, be a constant process of review and verification of records at the point of care. Confirm important information with the patient, especially when you are seeing a patient for the first time. If anything in the records seems unusual or illogical to you, check its validity – don’t assume that it’s you who is in error! (see Case 1.) Similarly, if you are prescribing medication or intending to carry out a surgical procedure in response to the transcribed results of a lab report or an investigation, check the actual report first if it is available, to make sure that the information in the medical notes is accurate (see Case 2).
Once an entry has been made in a medical record, it should not be deleted or obliterated, even if it is later found to be erroneous or misleading. If you need to make a correction, use a single black line to cross out the error and then add the amendment and your signature, name (in block capitals) and the date and time.
Checking the patient’s identity
One of the main causes of inaccuracies in medical records is that of mistaken identity (see, for example, Case 1). Experts in risk management recommend that healthcare professionals make it their normal practice to check a patient’s identity before a consultation, a procedure or administration of medication. The method they recommend is to ask the patient to state their name and date of birth rather than asking for confirmation that they are who you think they are – “Could you tell me your full name please?” rather than “Are you Mrs Okele?”.
Reports and test results can also be easily filed in the wrong patient’s records, especially if the patients share the same name, so it is important to double check that other details such as date of birth or an ID number match those on the cover of the records.