Why doctors should keep good medical records
By Vanessa Rogers on behalf of Indwe Risk Services (Authorised FSP 3425) and MC De Villiers Brokers (Authorised FSP 7241)
It’s a familiar scenario – doctors have dozens of people to see in a day and there’s little time for them to record what was wrong with each patient or what course of treatment was decided upon. Even though doctors know it’s important, record-keeping is frequently given low priority. Notes are often illegible, with information missing and gaps left as to the full treatment protocol. In some cases, there may even be an inconsistency between what different doctors recorded about the same patient (in the case of referral from one to another, or filling in and treating another doctor’s patients during a leave period, for example).
Yet medical records form a fundamental part of patient care. They’re the written record of what diagnosis a patient was given and what medicine was prescribed. They help other professionals to understand the doctor’s thought process at the time and the diagnostic conclusion they came to. Medical records can be electronic or handwritten and can include lab reports, X-rays and referrals from other doctors. According to Indwe Risk Services, when defending a complaint or clinical negligence claim, good medical records can make all the difference.
The importance of accurate and timely medical records
Maintaining good medical records isn’t just a necessity; it shows that doctors are taking care of their patients and meeting all their needs. Medical records should be clear, accurate and timely. They should be made every time a doctor sees their patient, and should be kept in chronological order to demonstrate the extent to which the patient is responding to their treatment. Doctors should make notes as they consult with their patient, or as soon as possible afterwards. It is also possible, especially in the case of illegible handwriting, for a doctor to record their notes on a dictaphone-type device or smartphone, and for an administrative assistant to type these up on a daily or weekly basis.
Another risk advisor, MC de Villiers Brokers, recommends that doctors note in full all decisions made and actions agreed to regarding their patient’s treatment. Informed consent forms part of this record-keeping process: patients need to be told what options are available to them and what side-effects some medications may deliver. According to South African law, a patient must provide their informed consent to any medical treatment that a doctor proposes.
What if a patient sues?
From a legal point of view, it matters little if the doctor did everything right at the time they treated the patient: if it is not recorded, there is no proof that something was done. This means, in the absence of good medical records, that even the best practitioners may be difficult to defend. MC De Villiers Brokers advises that doctors bear in mind that the quality of their record-keeping reflects the quality of the care they give their patients. In the case of malpractice allegations, the first thing that an attorney will ask for is the patient’s medical folder, so as to determine whether or not there was negligence.
To safeguard themselves, Indwe Risk Services advises that doctors should make detailed record-keeping an integral part of their daily routine. Doctors should always date and sign their entries, and should never alter or edit them. If they realise later that they’ve made a mistake, they should rather add an amendment. Practitioners should also bear in mind that patients have a right to access their medical records, so nothing offensive or discriminatory should be recorded.
Even with best practice, risks can only be reduced; never removed. By keeping complete, up-to-date and well-organised medical records, doctors can demonstrate the quality of care that they’ve given to their patients and can more effectively attempt to defend themselves against any legal claims or complaints that are laid against them.
Sources
https://www.bmj.com/content/348/bmj.f7716
https://www.samedical.org/images/attachments/guideline-on-informed-consent-jul012.pdf
Many doctors complain that they don’t have sufficient time to keep accurate records, but assuming this attitude comes at a price. If a patient decides to sue, a lack of appropriate record-keeping will mean the practitioner involved does not have the evidence to back him- or herself up in court.