Poor notes: why?
›› It is a recurring observation that poor record-keeping is one of the major obstacles for MPS in defending complaints of negligence. Yet writing patients’ notes is one of the chores drilled into all of us, especially when we are training as interns.
This practice seems to wane as we get more experience and the notes become shorter and shorter, to end in no notes at all sometimes! Is this because of too much confidence, laziness or sheer carelessness? I don’t think so.
It must be a combination of many factors. I wonder if MPS could design a study to investigate this matter, difficult as it may be. Thanks for a great journal.
Dr Gustav Mutesasira, GP, Grahamstown, South Africa
You are quite correct that an otherwise potentially defensible claim is often rendered indefensible if the practitioner’s recollection of events is not reflected in the records. You raise an interesting point in trying to understand why this happens. I am not sure how we could study this in a scientifically robust way, but perhaps there are analogies from other daily activities.
What is important is to continually remind ourselves how important good records are
When learning to drive, we are meticulous in following our instructor’s directions; look in the mirror, indicate and so on, and concentrate on when to depress the clutch, change gear and accelerate. As we become more experienced, not only does the process become easier, and a subconscious skill, we also sometimes cut corners and don’t concentrate on following all the rules we were taught at the outset.
What is important is to continually remind ourselves how important good records are; for continuity of patient care, as an indicator of the standard of our practice, and ultimately to enable unmeritorious claims to be defended. So it is no surprise that this is the topic in so many of our articles, features and case reports, as well as workshops and seminars. If you have any ideas about more that MPS could do, I would welcome hearing from you.