Adequate medical records enable you or somebody else to reconstruct the essential parts of each patient contact without reference to memory. They should therefore be comprehensive enough to allow a colleague to carry on where you left off.
Poor-quality medical records are not only a major cause of iatrogenic injuries, they also make it difficult to defend a clinical negligence claim or an HPCSA disciplinary inquiry; it is axiomatic that poor note-keeping is evidence of poor clinical practice. The common problems listed in Box 1 are all-too-frequent re-occurring themes in MPS case files.
Good medical records can be characterised as:
- Comprehensible and accurate
Box 1: Common problems
Any of the following may compromise patient safety or lead to medicolegal problems:
- Not recording negative findings
- Not recording the substance of discussions about the risks and benefits of proposed treatments, including no treatment
- Not recording drug allergies or adverse reactions
- Not recording the results of investigations and tests
- Illegible, unsigned or undated entries
- Not consulting the relevant records when seeing a patient
- Making derogatory comments
- Altering notes after the event
- Wrong patient/wrong notes.