Date Added: 20/08/2008
Viewed: 3512 times
Keeping good, accurate and contemporaneous records not only gives us a record of our activities, but provides an integral part of our overall duty of care to the patient.
We are all taught at school how to write records and this is reinforced to us constantly at lectures and through lifelong learning but we often fall into the trap of over abreviating or just writing simple notes. Many of us can feel that it distracts from the treatment/management of patients if we are dedicating time to this and not the "clinical" aspect of care. This is misleading as the records form part of this care.
It is a misconception that records are for our use. It must be remembered that any record can be requested by the patient or agents on their behalf at any time. We must also remember that regulatory authorities and even the police can gain access to these records (sometimes without the permission of the patient) to scrutinise them!
We are aware as a profession of the increasing litigatious nature of society as a whole and good record keeping can form part of the "defence" that the proper level of skill and care was provided to the patient in our delivery of treatment. Invariably there may be conflict of opinions of what occured at any given event, with the patient and the clinician disagreeing on what acctually happened. I have said before that often the patients version may be preferred over the clinicians. However, if the clinicians records can provide clear evidence that their account of events the reverse is true. It has to be remembered that a patients memory of an appointment will be better than that of the clinicians as they saw 1 clinician that time and the clinician could and more than likely would numerous patients the same day.
There is a difference between adequate records and excellent records. Adequate records will allow the clinician to build details of a patients care without using just memory. Excellent records will go further and will record things such as thought processes that were behind clinical decisions that were made. By doing this, they could anticipate why a particular course of treatment was undertaken (or not as the case maybe).
Knowing what to and what not to record sometimes comes from personal experience or from developing skills that we learn from lifelong learning. Note taking has developed significantly in the last 20 years from the short scribbled, barely legible note taking of the past to the detailed computerised records many of us use today.
If we work as part of a team (with a nurse) they can provide an additional level of backup in recording all conversations as they occur, essentially typing as we speak. This may not be possible for all and in this case it is important to write notes soon after the appointment to prevent loss of small thoughts that may be of relevance later. When we are are busy and under pressure, it is these details that we often overlook.
What makes a patient record?
Firstly, you must clear your mind of the myth that the record card is the patient record. Read on.
What makes a patient record?
The patients record is much more than the clinical notes alone. It includes the totality of everything we do in practice. This does not mean that it has to be recorded in the clinical notes, it just forms part of the whole record:
Treatment notes (including charts, perio charts, BPEs)
Current and historical MH
Radiographs (and any other type of imaging)
Any other results (pathology etc)
Any other diagnostic tools (bites, wax ups, models etc)
Any other information that may refer to the patient (appointment books, financial transactions etc)
What should the patient record contain?
Some of this information may be stored elsewhere. An example being financial records. Many practices will keep things such as visa slips in a seperate place. These still form part of the record in the whole.
Patients name, DoB, address, preferred contact means etc. These should be checked with the patient frequently.
An up to date MH which should include information of any self precribing. The patients GP should be recorded. This information should be checked at each subsequent visit and a formal entry made that it has been.
The date and time of any missed appointments and of of those the patient cancels, for whatever reason, and those when the patient arrives late and has to be rebooked.
A record should made of any phone contact with patients regardless of who contacts the patient. the date, time and content should be recorded in the records. This should nowadays include fax and emails.
Investigations of all kinds which includes BPEs and other indices and monitoring of any pathology and conditions.
Finacial transactions of all kinds. This should include copies of any quotes or estimtes, all fees paid and any unpaid fees.
All corespondence which includes any third party such as specialist referals and letters from consultaions elsewhere.
Consents of all kinds. This includes any verbal warnings with regards to adverse or otherwise outcomes.
Any advice that may have been given. This includes all OH, dietary or general health and should include any smoking cessation advice given or information opn any other risk factors. This should also include advice that may have been given by, for example, a recptionist.
Any instructions given to the patient both pre and post operatively.
Any administered drugs. Route, dose, frequency and quantity. Any adverse reaction must be recorded.
Anything else you consider relevant.
What does contemporaneous mean?
It means recorded at the time. Difficulties arise when a clinician feels the need to enhnce or embelish records after they realise that their version may be challenged. Few records will be perfect, but if challenged the clinician may possibly be embarassed by the inadequacy of the notes and feel the need to enhance them. All records should be in diary sequence and you should never attempt to cover tracks. The courts and regulatory authorities will never take this lightly.
Keeping records is not about "firefighting" or protecting ourselves from litigation but merely good practice. We should not be afraid to record adverse results as long as the patient is informed and it is recorded. If we have kept an accurate record of all our conversations, treatments and dealings with the patient, then we have nothing to fear!