Chapter 11: How to keep good medical records - worth their weight in gold
|"Record what you have seen; make a note at the time; do not wait. "
- Sir William Osler.
Most doctors dislike paperwork – especially that involved in entering information in medical records. Thus, while most surgeons enjoy operating, many treat documenting the medical details in the record as a painful chore which they would rather not do. This often means that entering data into the medical chart is delegated to a junior or inexperienced assistant, as a result of which it is often not done well.
Remember that the medical record serves many purposes , and its primary function is to plan for patient care. However, from the risk management perspective, the medical record is a crucial element in preventing and minimizing malpractice litigation. Ultimately, it serves as the basis for the defense of malpractice claims and lawsuits. Medical records which are poorly maintained, incomplete, inaccurate, illegible or altered, create doubt about the treatment given to a patient, and can be a major medical-legal liability. By contrast, proper documentation in the medical record creates a legal document which accurately and completely reflects the care provided to a patient and, in a courtroom setting, it may be likened to a witness whose memory is never lost.
While keeping good records is simply a matter of common sense, the mnemonic OLFACTORY, which stands for : Original, Legible, Factual, Accurate, Complete, Timely, Objective, Rationale and Yours, will help you to define a "good” medical record.
It is helpful to follow a system when making notes in the medical record, to ensure that all important information has been recorded. The SOAP system ( which stands for Subjective ( the patient’s history); Objective ( examination findings); Assessment and Plan ) is popular in many hospitals, and is easy to implement. Preprinted medical records can help to establish consistent documentation , ensuring you do not forget to record important information. They can also help to save your time when entering data.
When writing orders in the chart, it can be helpful to remember the following headings ( the mnemonic being ADCA VAN DIMS) , to ensure that important orders are not overlooked. Every doctor should develop their own systematic method to ensure completeness.
Special orders ( such as occupational therapy or consultations requested)
Each and every page of a patient record should be clearly labeled with the patients complete name and medical record number. Anyone making an entry in a patients chart should do so only on hospital approved medical record forms and then only with pen rather than pencil. Use only hospital accepted medical abbreviations and terminology. Associated records and tests such as EKGs, EEGs, fetal monitoring tracings, etc., should all be properly labeled with the patients name , medical record number, the date and time.
All entries in the medical record should be dated, the time they were made noted, and should be signed by the person making the entries. Progress notes should indicate that the patient was kept informed of his or her condition, as well as the treatment plan. Document all instances of patient non-compliance or refusal of recommended treatment and that the patient was informed of potential consequences. Many courts take the view that if it an event is not documented, it did not happen !
Patient records should never be altered. One should not erase, obliterate or attempt to edit notes previously written. All corrections, late entries, entries made out of time sequence, and addenda should be clearly marked as such in the record, and should be dated and timed on the day they are written and signed. Draw a single line through any erroneous chart entry and write "error" with the date and time, as well as your initials.
Don’t forget that the information you enter on a patient’s record is open to public scrutiny. Good medical notes are an excellent way of showing other doctors your clinical skills and competence. It’s also a good idea to go over the medical record with your patient, so that he understands exactly what you have entered and what it means.
this saves your time, it’s important that you review the facts carefully with the patient yourself.
You need to develop a system of keeping your patient’s records safely and securely. While this can be an additional burden, it’s well worth your while. Not only will it make it much easier for you to provide better care to your patients, your patients will also feel much more comfortable, knowing that you have all their medical details at the tip of your fingertips. The following suggestions will help you store your patient’s medical records safely.
By taking an organized approach to the problem, you and your staff wont be spending half the day looking for missing or misplaced records ! Many lawyers recommend that medical records be kept indefinitely. Older records can be archived and stored on microfilm or CD-ROM. However, do remember that even though the medical record is the property of the clinic, patients have a right to see their own records.