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The Importance of Accurate Medical Records

SyberScribe AUTHOR: SyberScribe, July 15th, 2014

Every medical professional and medical practice needs to keep accurate medical records. This is not only vital for the provision of good patient care, but necessary for the protection of the medical practitioner as well. This article looks at some of the reasons why accurate records should be kept at all times, and also offers some helpful tips on the best ways to achieve this.

Good patient care

In the past, doctors kept medical notes on their patients largely to remind them of their condition the next time the patient visited them. But with clinics now becoming the prevalent form of healthcare, a patient may not see the same doctor on every visit; having accurate records is vital to allow any practitioner to take over the patient’s treatment simply by referring to their records.

The absolute minimum standard for accurate medical record keeping requires that records be legible (preferably not hand-written and ideally digital) and contain:

  • The patient’s medical history.
  • The practitioner’s examination findings.
  • The provisional diagnosis reached.
  • Any other diagnoses that were considered.
  • The management plan, including recommended treatment, tests ordered and medications prescribed.

Personal protection

As well as ensuring good patient care, keeping accurate medical records can protect a medical professional from any disputes that might arise about treatment, alleged compliance breaches and even lawsuits that might be brought against them.

In a medically-related lawsuit it is always the patient’s medical records that are examined first, and ensuring they are accurate is a medical professional’s best defence against any allegations that might be made. For this reason, the records should always be entered in a timely manner and never altered or back-dated in any way.

Privacy laws also require that medical records are stored securely and made available to the patient upon request, and keeping timely and accurate records will help to protect a practitioner from any potential breaches of these laws.

Record keeping tips

The following tips can help to ensure that your medical records are accurate.

  • Make sure all entries are clear and readable.
  • Include all matters in your records that are relevant to the patient’s care, such as history, findings, diagnoses, treatments, care rendered and advice given.
  • Draw diagonal lines through any blank spaces left after a written entry.
  • If an error is made in a written entry, draw a line through it and write the time date and your initials in the margin. Never erase it or use white-out on it.
  • Initial or sign all entries, include the date and time and make sure the patient’s name is on every page.
  • Don’t use abbreviations, unless they are standard medical abbreviations.
  • Do not make any derogatory references to the patient that might be misconstrued at a later date.
  • Be specific at all times, and don’t use generalisations or subjective rather than objective language.
  • Ideally use a medical transcription service. This involves dictating your notes into a voice recorder or mobile device and then emailing or voice streaming them to an outside transcription service, often based in the cloud, for accurate transcription, storage and retrieval.

As a rule of thumb, it’s better to err on the side of caution and include too much information in your medical records rather than too little, because as the old saying goes, ‘If it’s not in the record, then it didn’t happen’.