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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.
Clinical record keeping is integral to good professional practise and the delivery of quality health care. A patient’s clinical records represent the formal record of a clinician’s work. The UK General Medical Council states that you should make records at the same time as the events you are recording or as soon as possible afterwards. The content and handling of clinical records is strictly regulated by the law in most countries, not only because they are fundamental to high-quality patient care, but also because they are increasingly used in the courts and represent an important source of confidential personal information.
More importantly for health care providers is that the courts tend to consider that if a medical decision, treatment, or procedure has not been documented in the clinical notes, then it has not been performed. Thus, in a court of law, it doesn’t matter if you’ve done your best for your patient unless you have accurately documented this fact. It is recommended that you should look up the relevant legal requirement in your own country and familiarise yourself with them. In all cases, ideally, make notes as the events have taken place or as soon as possible afterwards so as not to miss anything.
In 2004, Beverly Scott of the UK NHS Information Standards Board established that there is a lack of a standard model across the UK NHS for documenting and communicating information. The General Medical Council has clearly stated that clinical records should include relevant clinical findings, decisions made and actions agreed, and who is making the decisions and agreeing the actions, information given to patients, any drugs prescribed, or investigation or treatments agreed, and details of who is making the record and when it was made. These are general dos and don’ts for record keeping.
However, additionally for remote or triage consultation, it is also important to add whether it was a remote consultation so it is clear whether it was in the GP surgery, telephone, or via video link. And consent for a remote consultation must also be explicitly stated. Here, you can see an example of what poor record keeping would look like. If we start off with what has been added into the consultation notes, we know that the presenting complaint is a suspected UTI. There’s some vague history of the presenting complaint, information about the medication that’s been prescribed. Further investigation has been mentioned, and a footnote has been issued. However, there are still lots of things that are missing.
So for example, is the patient aware of what to do in case the symptoms get worse? The records state that if there is no improvement to come back, but what kind of nonimprovement are we looking at? And when should she come back, and who should she contact? In terms of an examination, if we have taken a urine dip, has that been done? But has the GP taken her temperature? Have they checked her pulse rate? If they have, it’s not documented, so by default, we can assume that none of this was actually carried out.
So as you can see, these are all questions that anybody would ask if they were following up or reviewing this patient if they came back in a few days. You as the clinician following up are not fully informed of how this patient was examined and what kind of information they were given. We cannot assume that the patient will always remember the information that the GP has given them. So using the same consultation here, we are going to look at how this clinician has documented with much more information, as we normally should. So again, if we start off by looking, it’s been clearly stated that it’s a telephone consultation. Presenting complaint– the clinician suspected a UTI.
There’s much more information about the history of the presenting complaint, and also, there’s more information on the type of examination that was carried out remotely. And as you can see, the clinician has also clarified that it was remotely checked by the patient themselves. There’s information regarding the patient’s social history, because it’s relevant in this case. And then we look at the discussion that the patient and the clinician have had, and there’s a set plan. So this example shows you how you should be documenting the notes.
So the clinician over here has discussed the length of treatment, when to expect improvement, what kind of symptoms to look out for in case the treatment fails, and what setting to attend, depending on the symptoms they’re experiencing, whether they need to come back to the surgery for a review with a clinician or they need to attend A & E. The patient has also been provided with additional information in case they forget what the GP has told them. As you can see, then, there’s a clear difference between the previous consultation notes and these notes.

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.

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