Tables
- Table 1
Advantages of keeping good clinical records and the disadvantages of poor clinical records
Good clinical records Poor clinical records Aid the sharing of relevant information and multidisciplinary team communication Misinform healthcare professionals and patients Aid coordination of care Increase medico-legal risks Aid continuity of care Lead to unnecessary repetition of tests or other investigations Aid informed decision making for patient management Prolong hospital admission Improve availability of data for risk assessment Jeopardise patient care Improve availability of data for route cause analysis in the investigation of serious incidents Lead 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
Do Do not Use timed entries Use abbreviations Make objective comments Make offensive, humorous or personal comments Document any noncompliance Use ambiguous terms Document oral communications (phone calls, in person conversations etc) and actions taken Delete or alter the contents of clinical notes in a way that is untrackable Document informed consent State objections regarding care or case management
Vol 12 Issue 4
Table of Contents
How to keep good clinical records
