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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:
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.
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’.