The importance of keeping good medical

records

Good quality medical records are an essential component of safe and

effective healthcare

Good medical records – whether electronic or handwritten – are essential for the

continuity of care of your patients. For health professionals, good medical records are

vital for defending a complaint or clinical negligence claim; they provide a window on the

clinical judgment being exercised at the time. The presence of a complete, up-to-date,

and accurate medical record can make all the difference to the outcome.

What are medical records?

❖ “any relevant record made by a health care practitioner at the time of, or

subsequent to, a consultation and/or examination or the application of health

management”.

Medical records cover an array of documents that are generated as a result of patient
care, these include:

1. Hand-written contemporaneous notes were taken by the health care practitioner.

2. Notes taken by previous practitioners attending health care or other health care
practitioners, including a typed patient discharge summary or summaries.
3. Referral letters to and from other health care practitioners.

4. Laboratory reports and other laboratory evidence such as histology sections, cytology
slides, and printouts from automated analyzers, X-ray films, and reports, ECG traces,
etc.

5. Audiovisual records such as photographs, videos, and tape-recordings.

6. Clinical research forms and clinical trial data.

7. Other forms completed during the health interaction such as insurance forms,
disability assessments, and documentation of injury on duty.

8. Death certificates and autopsy reports.

Top ten tips for - record-keeping

1. Always date and sign your notes, whether written or on the computer. Don’t change
them. If you realize later that they are factually inaccurate, add an amendment.

2. Any correction must be clearly shown as an alteration, complete with the date the
amendment was made, and your name.

3. Making good notes should become routine.

4. Document all decisions made, any discussions, the information is given, relevant
history, clinical findings, patient progress, investigations, results, consent, and referrals.

5. Medical records can contain a wide range of material, such as handwritten notes,
computerized records, correspondence between health professionals, lab reports,
imaging records, photographs, video, and other recordings, and printouts from
monitoring equipment.

6. Do not write offensive or gratuitous comments – eg, racist, sexist or ageist remarks.
Only include things that are relevant to the health record.

7. Remember patients have a right to access their own medical records under
Promotion of Access to Information Act (PAIA), No 2 of 2000.
8. Risks can never be eradicated, even with best practice, only reduced. Good
record-keeping helps to maintain best-practice, aiding clear communication between
professionals and demonstrates that best practice has been followed.

9. Complete, contemporaneous, and well-organized medical records are essential for

good medical practice and continuity of care. They are necessary for a healthcare
professional’s defense against a claim or complaint and can be seen to reflect the
quality of care provided.

10. Appropriate record-keeping is recognized as an important component of

professional standards.