How to write in the medical notesBMJ 2016; 353 doi: https://doi.org/10.1136/sbmj.h5703 (Published 11 May 2016) Cite this as: BMJ 2016;353:h5703
- Rachael Brock, clinical lead in national disease registration, Public Health England
Medical notes are the backbone of patient care. Good notes facilitate communication between doctors, nurses, and all the allied health professionals involved in the care of the patient. They are a continuous, honest, and contemporaneous record of management and decision making—they help colleagues carry on where you left off. Medical notes are also useful for health professionals when defending a complaint or clinical negligence claim; they provide a window on the clinical judgment being exercised at the time.1
As a foundation doctor, you’ll be responsible for much of the note taking on ward rounds and during multidisciplinary team meetings. It’s where you’ll document tasks that you have completed and any changes to patient conditions, or vital information from your on-call shifts. As a medical student your team might ask you to write in the notes under the supervision of a junior doctor. This article provides a guide on how to make notes that ensure joined-up care.
What are medical notes?
A patient’s notes consist of ward round notes, consultations—that is, visits from other specialties—results of investigations, and discussions with other professionals, patients, and relatives. Members of the multidisciplinary team such as nursing colleagues, physiotherapists, and occupational therapists also record their care in the notes. Some patients may move wards several times, and clear documentation helps with handovers.
You should follow good practice principles when taking notes. The General Medical Council says doctors should record their work “clearly, accurately, and legibly,” and it also stipulates that patient notes should be created contemporaneously and kept securely.2 The notes may be scrutinised in medicolegal cases so remember the adage, “if it isn’t written down, it didn’t happen.” Below are guidelines from the GMC and the Royal College of Physicians (RCP) on the content of clinical records.
Box 1: GMC requirements for clinical records2
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
Who is making the record and when
Box 2: Generic medical record keeping standards approved by the RCP3*
The patient’s complete medical record should be available at all times during their stay in hospital
Every page in the medical record should include the patient’s name, identification number (NHS number),† and location in the hospital
The contents of the medical record should have a standardised structure and layout
Documentation in the medical record should reflect the continuum of patient care and should be viewable in chronological order
Data recorded or communicated on admission, handover, and discharge should be recorded using a standardised proforma‡
Every entry in the medical record should be dated, timed (24 hour clock), legible, and signed by the person making the entry. The name and designation of the person making the entry should be legibly printed against their signature. Deletions and alterations should be countersigned, dated, and timed
Entries to the medical record should be made as soon as possible after the event to be documented—for example, change in clinical state, ward round, investigation—and before the relevant staff member goes off duty. If there is a delay, the time of the event and the delay should be recorded
Every entry in the medical record should identify the most senior healthcare professional present (who is responsible for decision making) at the time the entry is made
On each occasion the consultant responsible for the patient’s care changes, the name of the new responsible consultant, and the date and time of the agreed transfer of care should be recorded
An entry should be made in the medical record whenever a patient is seen by a doctor. When there is no entry in the hospital record for more than four days for acute medical care or seven days for long stay continuing care, the next entry should explain why§
The discharge record/discharge summary should be started at the time a patient is admitted to hospital
Advanced decisions to refuse treatment, consent, or cardiopulmonary resuscitation must be clearly recorded in the medical record. In circumstances where the patient is not the decision maker, that person should be identified—for example, lasting power of attorney
*Prepared by the health informatics unit of the RCPhysicians
†NHS number is being introduced as the required patient identifier
‡This standard is not intended to mean that the handover proforma should be used for every handover of every patient rather that any patient handover information should have a standardised structure
§Maximum interval between entries in the record would in normal circumstances be one day or less
What to write in the medical notes
An example of what should be included in the notes as part of the ward round can be seen in figure 1. Write in black indelible ink—it cannot be changed and it is easily photocopied or scanned.⇓
Medical students writing in the notes
Medical students can write in the notes, but they should clearly document their authorship and their entry must be countersigned—usually by a junior doctor who verifies the account as an accurate representation of what happened. Writing in the notes is great practice for medical students, and it can free up junior doctors to do other jobs. Sign the notes at the bottom of your entry.
Hospital admissions are usually documented using a proforma, which includes presenting complaint and background information such as medical, social, and family history. The clerking is key to determining comorbidities and usual medications, as well as details of next of kin, which can be vital if the patient deteriorates. The most recent observations, tests, and investigations, as well as a plan for further investigation and management must also be documented. For acute admissions, when a patient’s condition can often change rapidly, document whether the patient seems sick or well, and if he or she is oriented to time, place, and person. This will give a frame of reference for the next doctor reviewing the patient after handover. As well as assisting the registrar with the management of an acutely unwell patient, junior doctors are expected to clearly document all the investigations and management decisions that have been made.
Discharge summaries are read by patients and GPs. They also provide essential information to emergency department doctors if the patient presents with an unexpected complication soon after discharge from hospital. The discharge summary should include the patient’s comorbidities and drugs on discharge as well as accurate details of the admission, findings, and procedures. Follow-up clinic appointments are booked by ward clerks on the basis of the discharge summary alone, so remember to document whether outpatient follow-up is required. It is worth noting that thorough clerking at admission can save you and your colleagues time when filling out the discharge summary.
Be careful when asking GPs to complete tasks. For example, “GP to check outpatient ultrasound scan result” would not be an appropriate request because the clinical team organising a test is responsible for reviewing the results. However, “Patient requested to have repeat liver function tests at GP surgery in one week please” will be better received by the primary care team.
What not to document
Do not make any comments in the notes that you would not make in front of a patient. Particular words you should avoid include alcoholic (although “smelling of alcohol,” or “previous documented alcohol dependency” are appropriate), obese (unless clinically supported by the body mass index—and “raised BMI” might be better), and any words or phrases that could be perceived to have a pejorative tone. Judgmental comments—even when positive (for example, “this charming lady”)—are probably best avoided. Doctors aiming to convey a patient’s individuality in the notes might instead choose to objectively document the person’s home circumstances, interests, or hobbies.
Beware of documenting negative comments about colleagues. Exclamation marks, emoticons, and humour have no place in the medical notes because they can be misconstrued. Documentation should encourage and reflect supportive teamwork.
Particular care should be given to discharge summaries because they are routinely given to patients when leaving hospital. For example, patients with a diagnosis of cancer should be sensitively informed before receiving a copy of a discharge summary detailing this. If the discharge summary is being written by a doctor who has not been involved in the patient’s care this should be clearly stated. Words like “inoperable” or “end stage” should also be used with care. Typos and inaccuracies give a bad impression to the patient, so even if the discharge summary is short, it should be as neat and correct as possible.
Keeping up on the ward round
The quality of the ward round documentation is dependent on the junior team members keeping up with the speed of the ward round. The key is to be quick and efficient. If you think that you do not have enough time to write an adequate entry, raise this as a problem.
Having spare continuation sheets to hand, name stamps, and writing section headings before the consultation can speed up the note taking process. If there is more than one foundation doctor on a ward round, alternating the note taking of patients is often effective.
Other forms of preparation can help the team save time. Blood results and imaging results should be readily available and filed in the patient’s notes. An organised notes trolley, stocked with spare pens and paperwork (continuation sheets, consent forms, and do not attempt resuscitation forms, for example) can also save time.
Weatherall L, Patel R. How to prepare for a ward round. Student BMJ 2015;23:h4362
Stopford E, Ninan S, Spencer N. How to write a discharge summary. Student BMJ 2015;23:h2696.
Arasaratnam R. Medical ward rounds. Student BMJ 2009;17:b576.
Originally published as: Student BMJ 2016;24:h5703
Competing interests: None declared.
Provenance and peer review: Commissioned; externally peer reviewed.