Medical Records

The main purpose of medical records is to facilitate patient care and allow another practitioner to continue the management of the patient. In a hospital setting, where there may be a number of health professionals involved in a patient’s care, good medical records are vital to ensure continuity of patient care.

Good medical records should allow another practitioner to easily understand the patient’s current condition and continue their care. The challenge is to make accurate, comprehensive and concise notes, presenting the information in a logical order, with important information highlighted. Your entries should be signed and include the date and time that the entry was made.

Good medical records are also your best defence in the event of a complaint or a medical negligence claim.

What should be included in the medical records?

Medical records should include the history, examination findings, investigations that have been ordered, provisional diagnosis and treatment plan. In general if you are called to review a patient, then you should record this in the notes. If you ask for advice from another doctor, then make a note of the conversation in the notes. If you have tried to contact another doctor and have been unsuccessful, then it may be worth recording that briefly in the notes as well. What should NOT be included in the medical records? Medical records should be objective so avoid emotive language. Avoid derogatory comments about the patient or your colleagues. Remember that patients have a right to access their medical records and can obtain a complete copy on request.  Never record anything that you would be embarrassed to hear or read out loud in court.  Do not use abbreviations and acronyms unless they are commonly used and approved by your hospital. For example, MS may indicate multiple sclerosis or  mitral stenosis.

How do I make additions or corrections to the medical records?

Medical records should not be destroyed or altered.  If you need to make a correction it is acceptable to rule across the mistaken entry and initial the correction indicating that the notes were written in error. Do not use correction fluid, or tear out part of a page.

If you need to add something to a previous entry, add the addendum chronologically in the notes, explaining to what entry it refers. The entry should clearly be marked as “additional” and include the time and date that the additional entry was made.

Want to know more about writing medical records? 

If you have concerns about a medico-legal situation including medical records, contact our 24/7 Medico-legal Advisory Service on 1800 011 255.

 *Answers: FLK (Funny Looking Kid), FOS (full Of S*** – implying patient could be constipated, or stupid), GOMER (Get Out of My Emergency Room – from Samuel Shem’s classic novel The House of God, referring to an elderly demented patient). Derogatory and confusing acronyms such as these should never be recorded in the notes.