The integrity of the medical record should be maintained by using which procedure
Clear, accurate records support clinical decision-making and patient care. Show 2 February 2021
The purpose of recordsIn Good medical practice, the GMC says you 'must record your work clearly, accurately and legibly.' Clinical records fulfil several important functions.
Recording a consultationIn order to best support patient care, your consultation notes should be made as soon as possible and include the following details:
Patient records: what else to includeAs well as face-to-face consultations, you should record all interactions with patients and any information relevant to their care, including:
The integrity of recordsMake every effort to preserve the integrity of your records so they support patient care and you're not vulnerable to criticism in the event of a complaint or claim. To help with this, make sure your notes are: CompleteAs described above, ensure your notes are an accurate reflection of what took place during a consultation and that all relevant information is filled with the patient's record. ContemporaneousWrite notes as soon as possible while events are still fresh in your mind. Timely record keeping is important if colleagues need to see the patient again soon afterwards. Clear and legibleWhen you need to make a note by hand, take a little extra time and care to write legibly so you and others can read it later. Entered for the correct patientDouble-check you're saving notes into the correct patient record, especially when they have a common surname or the whole family is on your practice list. Don't include ambiguous abbreviationsSome abbreviations for conditions and medication are open to misinterpretation and can confuse other members of the healthcare team. Limit them to those approved in your workplace. Avoid jokey commentsOffensive, personal or humorous comments could undermine your relationship with the patient if they decide to access their records and damage your professional credibility if the records are used in evidence. Not tampered withNever try to insert new notes or delete an entry. In written notes, errors should be scored out with a single line so the original text is still legible and the corrected entry written alongside with the date, time and your signature. If you remember something significant you can make an additional note, but it should be clear when you added the information and why. Computerised entries will have an audit trail of all entries and deletions, so if something is deleted there should also be a clear record as to why that was done. CheckedIf notes have been dictated and transcribed by a third party, review them for transcription errors and sign entries before they are added to a patient's records. You should also check, evaluate and initial printed results, reports or letters before they are filed in the patient's records and document any appropriate action. This page was correct at publication on 02/02/2021. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers. |