What does PND mean - post-nasal drip or paroxysmal nocturnal dyspnoea? It may be clear to the author but could be ambiguous to others reading the records at a later date. Use abbreviations with care.
Never use derogatory and offensive comments. Not only is this highly unprofessional, but patients and others have a right to access their notes under the Data Protection Act. Be respectful, as your records could be seen by colleagues, patients, their families…and their lawyers.
Include date and time
This is particularly important from a medico-legal perspective, as a claim could be brought by a patient years after the event. Memories fade with time and you may not be able to recall exactly when you treated someone or were involved in their care.
Never tamper with notes
This has led to GMC investigations. Never try to hide errors or disguise additions. As a general rule, errors should be crossed out with a single line so the original text is still legible and the corrected entry written alongside with the date, time and your signature. New additions should be separately dated, timed and signed by the doctor who made them.
Never try to insert new notes, regardless of the format. While it might appear easy to alter digital records, computerised systems have an audit trail that will allow changes to be discovered.
Typed and dictated notes have the advantage of being clearer, but you should make sure no errors have accidentally crept in during the process. They should be checked, corrected and signed by the doctor who dictated them.
Finally, it's a good idea to be familiar with the Data Protection Act 1998. This act allows patients to view their records or receive a copy of them, subject to some exceptions.
As a student you have probably had little, if any, experience of writing medical notes or transcribing the consultant's directions during a ward round.
As a doctor, however, you will be bound by the GMC guidance in 'Good medical practice' (2013), which lays out the principles for good record keeping. It states that in providing good clinical care, all documents you make, including medical records, 'must be clear, accurate and legible'.
It also says that records should be made at the same time as the events you are recording (or as soon as possible afterwards) and that they must be kept securely.
Reasons to be clear/full - 1, 2, 3…
Records should include clear and complete information, including relevant clinical findings, decisions made and actions agreed and by whom, information given to patients, drugs prescribed and details of who is making the record and when.
Legible and complete notes provide an accurate picture of treatment, along with enabling continuity of care and good communication with your colleagues. Patients and other parties also have a right to access their records, so they must be suitably written.
It's not just other people who rely on your notes. If there was ever a problem with a patient's treatment, how would you justify your actions and decisions? Your records can serve as legal evidence and protect you if you're ever called on to defend yourself, so it's vital that they’re of good quality.
Here are some top tips for good record keeping:
Can other people read your handwriting? Some records may now be computerised, but in the hospital setting this may not always be the case. One doctor's script is another's scrawl.
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