The importance of good, clear and thorough medical records cannot be underestimated - not only do they ensure the smooth running of your day-to-day life in practice; they might prove invaluable in the event of a claim. Rosie Wilson looks at how a Medical Protection workshop can enhance your skills in making and keeping quality medical records.
Maintaining clear, coherent and effective notes might seem straight forward, and although we may feel confident in our practice 99% of the time, each case is unique and even the most experienced practitioners can come up against bumps in the road. Dealing with specific areas of concern, as well as improving overall practice can help put you at ease both personally and professionally.
We believe that the best way to learn a skill is with tangible training and education, which is why we’ve developed a specialist workshop for GPs on taking the most effective notes possible.
We also understand that GPs are pushed for time and under increasing pressure, so as well as what should go into effective notes, the workshop focuses on realistically fitting these into a working day.
Even for doctors who are relatively comfortable with record keeping and have developed their own style, it’s easy to have specific concerns, like:
“How do I document a consultation with a patient who has asked me to speak off the record?”
or
“Is it OK for me to go back into my notes at a later date to amend routine errors and add coding?”
These areas of ambiguity can make all the difference to a claim, so understanding the nuances of note-taking is highly important.
Three top tips for note keeping from the workshop include:
-
Keep full and thorough notes
Try and keep all records electronically as much as possible. Obviously, the main patient records will be stored on a database, but try and discourage practice staff from leaving paper notes or from asking for a quick word when they have a spare five minutes. Ensuring there is an audit trail for all your notes not only safeguards you and your practice, it makes for the best possible quality of care for your patients, too.
Case study
A boy of six months suffered with diarrhoea and vomiting. His GP was called and treatment was provided at home. Due to severe dehydration, he became both physically and mentally handicapped. When he was in his 20s, a solicitor suggested investigating the circumstances surrounding the illness and a claim of negligence arose. By this time, the GP had died, leaving only brief medical records of his consultations. In the absence of any robust evidence to the contrary, the claim against the doctor’s estate had to be settled.
-
Use templates
Make use of any templates that are stored on your practice’s system. These are usually very comprehensive and include everything you might need to write in medical notes, so following them makes the whole process a little more systematic and ensures you don’t forget anything.
Case study
A 43 year old male offshore worker was taking Methotrexate for Crohn’s disease and it was recommended he have six weekly blood monitoring. Every month he requested his prescription and it was issued. The GP tried to contact him to arrange a blood test, but his wife said that she believed he was visiting a doctor at work.
Four months later the practice was contacted as the patient had been admitted to hospital with pneumonia. His white cell count was dramatically reduced and the doctors believed the Methotrexate had caused this.
Happily he made a full recovery. However, the use of a Methotrexate template, where the dose prescribed and the date and result of the last blood tests were recorded, could have prevented this unfortunate episode.
-
Avoid ambiguity
Avoid ambiguity or acronyms where there is any reasonable doubt as to their meaning – misinterpretation could lead to problems later down the line. If you prefer to use a lot of coding, consider establishing a key for your whole practice to refer to.
Case study
A 38-year-old woman phoned her GP surgery complaining of back pain and difficulty passing urine. The GP checked her notes and saw a reference to PID, which he interpreted as pelvic inflammatory disease. He concluded that she had another urinary tract infection and wrote a prescription for antibiotics for the patient to collect. In fact, PID referred to her recurring problems with a prolapsed intervertebral disc which had now given rise to a cauda equina syndrome and associated pain and urinary symptoms.
Learn more at our workshop
By attending Medical Records for GPs, you’ll have the opportunity to discuss with peers and Medical Protection experts what constitutes good notes and how to protect yourself and your practice through diligent record taking. Attendance not only ensures that you know how to take the best notes possible going forward; it also counts towards your CPD.
Find out more or to book a place
Back to all GP articles
Please note: Medical Protection does not maintain this article and therefore the advice given may be incorrect or out of date, and may not constitute a definitive or complete statement of the legal, regulatory and/or clinical environment. MPS accepts no responsibility for the accuracy or completeness of the advice given, in particular where the legal, regulatory and/or clinical environment has changed. Articles are not intended to constitute advice in any specific situation, and if you are a member you should contact Medical Protection for tailored advice. All implied warranties and conditions are excluded, to the maximum extent permitted by law.