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How to keep good clinical records

Alexander Mathioudakis, Ilona Rousalova, Ane Aamli Gagnat, Neil Saad, Georgia Hardavella
Breathe 2016 12: 369-373; DOI: 10.1183/20734735.018016
Alexander Mathioudakis
1Institute of Inflammation and Repair, Wythenshawe Hospital, University of Manchester, Manchester, UK
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Ilona Rousalova
21st Dept of Tuberculosis and Respiratory Care, 1st Medical School and General University Hospital, Charles University in Prague, Prague, Czech Republic
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Ane Aamli Gagnat
3Dept of Clinical Science, University of Bergen, Bergen, Norway
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Neil Saad
4Faculty of Medicine, National Heart & Lung Institute, Imperial College, London, UK
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Georgia Hardavella
5Dept of Respiratory Medicine, King’s College Hospital, London, UK
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  • For correspondence: georgiahardavella@hotmail.com
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Tables

  • Table 1

    Advantages of keeping good clinical records and the disadvantages of poor clinical records

    Good clinical recordsPoor clinical records
    Aid the sharing of relevant information and multidisciplinary team communicationMisinform healthcare professionals and patients
    Aid coordination of careIncrease medico-legal risks
    Aid continuity of careLead to unnecessary repetition of tests or other investigations
    Aid informed decision making for patient managementProlong hospital admission
    Improve availability of data for risk assessmentJeopardise patient care
    Improve availability of data for route cause analysis in the investigation of serious incidentsLead to serious incidents
    Improve audit capabilities
    Provide informative evidence in a court of law
    Aid targeting of diagnostics and treatment plans without unnecessary repetition
    Improve time management
  • Table 2

    Structured information which needs to be included in clinical records

    Clinical notes should include
    Patient demographics
    Reasons for the current visit
    The scope of examination
    Positive exam findings
    Pertinent negative exam findings
    Key abnormal test findings
    Diagnosis or impression
    Clear management plan and agreed actions
    Treatment details and future treatment recommendations
    Medication administered, prescribed or renewed and any drug allergies
    Written (or oral) instructions and/or educational information given to the patient
    Clear documentation and justification for resuscitation status and ceiling of care (if inpatient)
    Documentation of communications with patient and family/friends (level of awareness of the situation and acceptance of the plans)
    Recommended return visit date
  • Table 3

    Basic do’s and don’ts in clinical record entries

    DoDo not
    Use timed entriesUse abbreviations
    Make objective commentsMake offensive, humorous or personal comments
    Document any noncomplianceUse ambiguous terms
    Document oral communications (phone calls, in person conversations etc) and actions takenDelete or alter the contents of clinical notes in a way that is untrackable
    Document informed consent
    State objections regarding care or case management
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Vol 12 Issue 4 Table of Contents
Breathe: 12 (4)
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How to keep good clinical records
Alexander Mathioudakis, Ilona Rousalova, Ane Aamli Gagnat, Neil Saad, Georgia Hardavella
Breathe Dec 2016, 12 (4) 369-373; DOI: 10.1183/20734735.018016

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How to keep good clinical records
Alexander Mathioudakis, Ilona Rousalova, Ane Aamli Gagnat, Neil Saad, Georgia Hardavella
Breathe Dec 2016, 12 (4) 369-373; DOI: 10.1183/20734735.018016
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