Dr Shelagh Turvill
Getting into the habit of keeping clear, accurate records will serve you well in the future
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.