What is healthcare documentation for?

The primary purpose of documentation in the patients’ healthcare record is to support direct patient care as an aide memoir but also as a method for communication.

Secondary functions

Secondary functions might be described as a medico-legal record for [1];

• Clinical audit and research
• Resource allocation
• Epidemiology
• Service planning
• Performance monitoring

Historically, healthcare records have been kept in a variety of ways however the first major attempt to standardise them came following the publication of the Tunbridge report in 1965. In his report, Tunbridge proposed that the then so called ‘medical records’ should be standardised and mechanised, so that the new methods of sorting and storing information on computers could be used to full advantage [1].

Standards of care

Documentation is a key ‘standard of care’ in its own right, when we think about fulfilling our ‘duty of care’ to patients. In the event of an investigation, documentation in the healthcare record is often the only way that we can demonstrate that we adhered to the standards of care for our patients.

The following points summarise some additional key points regarding documentation in the healthcare record:

• Supports safe clinical practice and continuity of care. They can also provide evidence in the event of a complaint or claim.
• Should be an accurate picture of your interactions with patients, whether face to face, by telephone or email.
• Should include all information relevant to the patient’s clinical care, including results and referrals.
• Should be made ‘contemporaneously’ or as soon as possible after the clinical encounter to help ensure they are an accurate reflection of what took place.
• It should always be clear who made a documentation entry, and when.
• Try to avoid amending records, unless it is to correct factual errors. It should be clear who made the correction and why.

[1] Mann, R. and Williams, J., 2003. Standards in medical record keeping. Clinical medicine, 3(4), p.329.