Intended for healthcare professionals

Careers

Medical record keeping: clarity, accuracy, and timeliness are essential

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.f7716 (Published 09 January 2014) Cite this as: BMJ 2014;348:f7716
  1. Wedad Abdelrahman, CT2 general medicine1,
  2. Abdelrahman Abdelmageed, consultant obstetrician and gynaecologist2
  1. 1Belfast City Hospital, Northern Ireland
  2. 2South-West Acute Hospital, Northern Ireland
  1. wedadabdelrahman{at}doctors.org.uk

Abstract

Medical records form a permanent account of the care a patient has received. Wedad Abdelrahman and Abdelrahman Abdelmageed explain why it is important that these records are well maintained

Medical records are a fundamental part of a doctor’s duties in providing patient care. As well as handwritten clinical notes, medical records include emails, scanned records, consent forms, text messages, verbal correspondence between health professionals, laboratory results, X ray films, photographs, video and audio recording, and any printouts from monitoring equipment.

The records form a permanent account of a patient’s illness. Their clarity and accuracy is paramount for effective communication between healthcare professionals and patients. The maintenance of good medical records ensures that a patient’s assessed needs are met comprehensively.

Information in medical records should be documented on a daily basis and in chronological order demonstrating continuity of care and response to treatment. The information should be comprehensive enough to allow a colleague to carry on where you left off.

Low priority

Despite this importance, medical record keeping is often given a low priority. Notes are often poorly maintained and sometimes patient notes are not readily available.1 It is common to find illegible entries, offensive comments, and missing information, and there is often inconsistency between entries by doctors, nurses, and midwives.

Editing medical records is evidence that they are inaccurate and makes them impossible to defend. The General Medical Council clearly states that records should be made at the time the events happen, or as soon as possible afterwards.2

Poor record keeping is a major factor in litigation cases brought against healthcare professionals.3 When patients seek legal advice—for example, in cases of malpractice allegations—the attorney’s first task is to review the patient’s notes and determine whether any injuries were caused by negligence.

No standard model

In 2004, Beverley Scott of the NHS Information Standards Board established that there is a lack of a standard model across the NHS for documenting and communicating information. To achieve good medical practice, health professionals must keep up to date with legal requirements and record keeping; professional bodies should outline what they expect from their members; and organisations should have standardised procedures for recording and communicating information.4

The General Medical Council has clearly stated that clinical records should include relevant clinical findings; decisions made and actions agreed, and who is making the decisions and agreeing the actions; information given to patients; any drugs prescribed or other investigation or treatment; and details of who is making the record and when it was made (box).2

Tips for good record keeping5

  • Write legibly

  • Include details of the patient, date, and time

  • Avoid abbreviations

  • Do not alter an entry or disguise an addition

  • Avoid unnecessary comments

  • Check dictated letters and notes

  • Check reports

  • Be familiar with the Data Protection Act 1998

From a litigation point of view, even if everything was done correctly at the time of an incident, if it has not been documented, it has not been done. This makes even the best of doctors difficult to defend.

When recording medical information, remember to keep it simple, and be mindful that the quality of the case record is assumed to reflect the quality of care delivered. Write down what you said, what you did, what you were told, and what you observed. Spending 15 minutes writing an accurate and detailed note can save a huge amount of thinking time 15 years later.

Footnotes

  • We have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.

References

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