Documentation

Medical documentation should authentically represent every consultation and is primarily intended to support patient care. Good record-keeping means you or a colleague can reconstruct key parts of each patient contact without relying on memory.  In an event of a complaint or clinical negligence claim, evidence in the clinical records will be largely considered.

Key points for good record keeping:

  • Clear, accurate, objective and legible documentation.
  • Every page in the medical record should include the patient’s name, identification number (NHS number/hospital number) and location in the hospital.
  • Every entry should be dated, timed using the 24-hour clock and signed by the person making the entry.
  • Every medical record should identify the most senior healthcare professional present at the time of entry and the team present.
  • Make records at the same time as the event you are recording or as soon as possible afterwards.
  • If you have obtained information from another colleague, record who provided this information, their designation and what was stated.
  • Avoid abbreviation as it may lead confusion among staff.
  • If you have to make an amendment to your notes, make sure it is clear why this was made. Do not obliterate the entry you wish to correct, instead run a single line through it so it can still be read. Make sure the correction has a date, time and signature.
  • Sign your entry including a printed name against your signature and your designation.

Further reading and resources:

By Dr Lola Meghoma (FY2)

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