Keeping Accurate Clinical Records is Paramount

Let's put the doctor's handwriting jokes to one side, and give a serious look at keeping clinical records.

Making sure that a patient's records are kept up to date is fundamental to any medical practice, and failure to do so properly can result in a malpractice case very quickly.

But, oddly, it drops down low on the priority list with most practices.

The types of records that need to be kept and recorded, cover not only those scribbles on a patient's folder but also consent forms, x-ray films, audio recordings, text messages, laboratory results, scanned records, emails, and also video recordings.

If at any time, any of these need to be called on, it should be an efficient process with very clear reproduction of the said record.

So, how can you keep effective clinical records and stay out of trouble?

Here are our 8 easy steps:

1. Document everything, from the verbal word to the voice recording, and to the written notes - make sure your patient always sign the consent form. Where the patient is unable to do so, then a close relative or family responsible should do so for them

2. Ensure that you use a digital recording system, as well as a generic filing process. It is best to double up on your record keeping

3. Make timed entries so that you can pinpoint exactly when each consultation took place when each piece of communication and each relevant document was received and passed on

4. Use clear and legible handwriting and also be detailed in your notes - If you go back to change any of your records, write clearly and indicate the date of amendment

5. Avoid abbreviations - literally write out everything in full (even if this means taking more time over your note recording)

6. Use objective language and avoid being ambiguous - this can just cause confusion and if a medical malpractice case does arise will prompt suspicion

7. Check all records twice over before closing the file - whether it comes from a third party, your receptionist or notes you made yourself, check all details to ensure they make sense and are accurate

8. Make detailed notes about non-compliance - whether this comes from the patient's side or from a third party - do not spare any detail here

And, remember, that a patient has the right to have access to their own medical records at any time. You want their file to always be up to date and ready for any emergency or request.

For more on medical malpractice and how we can assist, make contact today.

https://www.liabilityprotection.co.za/malpractice

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