The importance of keeping good medical records

Good quality medical records are an essential component of safe and effective healthcare

Good medical records – whether electronic or handwritten – are essential for the continuity of care of your patients. For health professionals, good medical records are vital for defending a complaint or clinical negligence claim; they provide a window on the clinical judgment being exercised at the time. The presence of a complete, up-to-date and accurate medical record can make all the difference to the outcome. 

What are medical records?

You are obliged by the HPCSA to keep adequate medical records. The HPCSA defines a medical record as “any relevant record made by a health care practitioner at the time of, or subsequent to, a consultation and/or examination or the application of health management”.¹

Medical records cover an array of documents that are generated as a result of patient care. According to the HPCSA, these include:

2.1.1 Hand-written contemporaneous notes taken by the health care practitioner.

2.1.2 Notes taken by previous practitioners attending health care or other health care practitioners, including a typed patient discharge summary or summaries.

2.1.3 Referral letters to and from other health care practitioners.

2.1.4 Laboratory reports and other laboratory evidence such as histology sections, cytology slides and printouts from automated analysers, X-ray films and reports, ECG traces, etc.

2.1.5 Audio visual records such as photographs, videos and tape-recordings.

2.1.6 Clinical research forms and clinical trial data.

2.1.7 Other forms completed during the health interaction such as insurance forms, disability assessments and documentation of injury on duty.

2.1.8 Death certificates and autopsy reports.²

Top ten tips for - record keeping

1. Always date and sign your notes, whether written or on computer. Don’t change them. If you realise later that they are factually inaccurate, add an amendment.
2. Any correction must be clearly shown as an alteration, complete with the date the amendment was made, and your name.
3. Making good notes should become routine.
4. Document all decisions made, any discussions, information given, relevant history, clinical findings, patient progress, investigations, results, consent and referrals.
5. Medical records can contain a wide range of material, such as handwritten notes, computerised records, correspondence between health professionals, lab reports, imaging records, photographs, video and other recordings and printouts from monitoring equipment.
6. Do not write offensive or gratuitous comments – eg, racist, sexist or ageist remarks. Only include things that are relevant to the health record.
7. Remember patients have a right to access their own medical records under The Data Protection Act.
8. Risks can never be eradicated, even with best practice, only reduced. Good record-keeping helps to maintain best practice, aiding clear communication between professionals, and demonstrates that best practice has been followed.
9. Complete, contemporaneous and well-organised medical records are essential for good medical practice and continuity of care. They are necessary for a healthcare professional’s defence against a claim or complaint and can be seen to reflect the quality of care provided.
10. Appropriate record-keeping is recognised as an important component of professional standards.

Find out more

• Earn CPD by visiting Medical Protection’s e-learning site
• Get in touch - tell us about your experiences on the wards
• Read our guide on good medical records

More support from Medical Protection
If you need advice, contact a medicolegal adviser at medical.rsa@medicalprotection.org
or 0800 982 766.

References

1. HPCSA, Guidelines on the Keeping of Patient Records, HPCSA: Pretoria (2008)
2. Ibid