On the record: the importance of keeping good medical notes

Nov 8, 2016

Historically, the purpose of a medical record was to aid a doctor’s memory. Times have changed, as have the perceptions and expectations of patients, as well as the purpose and requirements of the content of medical records.

It is widely accepted that although the record may physically belong to the doctor or practice, under provisions of the Privacy Act (as well as state-based privacy legislation) the patient has, in all but a few circumstances, the right to access their medical record. At the start of your medical career, it is important to understand why records are so important, as well as what should - and shouldn’t - be included in them.

A minimum standard

There is an expected minimum standard for the content of medical records as outlined in section 8.4 of the Code of Conduct for Good Medical Practice.

As a basic principle, each medical record should contain sufficient information to enable another practitioner to take over the care of the patient.

When writing your notes, think of what you would want to know from the records if you were taking over the care of the patient and hadn’t spoken to the previous doctor.

From a practical patient care and risk-management perspective, it is important that your records are sufficiently detailed, legible and are made contemporaneously. Ideally, they should contain:

  • The history obtained from the patient, including positive and negative features; 
  • Your examination findings, both positive and negative findings that impact upon the differential diagnosis 
  • The provisional diagnosis reached
  • Any differential diagnosis considered
  • The management plan, including the options discussed with the patient, the treatment recommended, prescriptions given and tests ordered
  • Appropriately detailed consent 


You should not alter, delete, interfere with, or backdate your medical records. These actions may not only contravene some state regulations, but will almost always make your records less reliable in any proceedings brought against you. Patients can request that you correct personal information they consider is inaccurate, but this should only be done in a way that is consistent with the state regulations and makes it very clear that a correction has been made in the record.

You must never write anything in the records that would be insulting or derogatory in the eyes of the patient or anyone else for that matter! This is clearly unprofessional, unethical, and fails to comply with behaviour expected by the Code of Conduct.

When you are writing in a patient’s record, always assume that someone else may read it in the future. For instance, an entry such as “healthy appearing decrepit 69-year-old man” may certainly insult the patient or their relative. Or in the case of a barely legible referral letter, the word “above” appeared to be “whore” when referring to the patient.

It is important not to overlook any clinically relevant observations such as those relating to the behaviour of the patient but take care in the choice of wording. For example it may be very relevant to note that the patient was rude, swore or smelled of alcohol but when referring to alcohol intoxicated patients, don’t use colloquial abbreviations or synonyms.

Records must be securely stored

When you have finished making notes, make sure you store the records securely where they will not be subject to unauthorised access. For more information refer to the Privacy Act 1988 and the relevant state legislation.

For the protection of your patient as well as you

First and foremost, medical records assist with the professional, smooth and safe care of the patient and enable everyone in the health care team to access the same information.

But they are also there for your protection. When patients complain, when there is an investigation by a disciplinary body, when there is a dispute between two versions of events, or when there is a lawsuit afoot, everyone always seeks the records and asks the question: what do the records say?


More information

Read our article on ‘Medical records – the essentials’.
Visit the Avant Learning Centre for more resources on Documentation and medical records.
Read the Medical Board of Australia’s Code of Conduct Good Medical Practice.

 

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We welcome your feedback on this article – email the Editor at: editor@avant.org.au