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You’ll thank yourself later: Why maintaining good records is crucial

As a young health professional embarking on your professional career, developing good routines and habits might just make the difference between a patient complaint against you being upheld or dismissed.

You will have found that when taking a history, there is structure in the processes in the same way a pilot might use a checklist in order that nothing is overlooked. This is built in to your history-taking, examination structure, differential diagnosis and so on.

The outcome of a complaint against health professionals very often hinges on the quality of the records they have made and kept. So many health professionals have been let down in recent years by the quality and content of the records they have made. Remember too, telephone or Zoom discussions also count as consultations, for which some record should be kept.

Ideally, the notes should include:

  • the context for the consultation

  • recording of relevant history and examination

  • any decision-making process and plan

  • information discussed or given to the patient

  • consents where relevant

  • the next steps.

Obviously with workload pressures and time constraints, not all consultations require comprehensive notes, but these must be tailored appropriately to the encounter.

The Medical Council Statement on Managing Patient Records December 2020 provides the guidance on what notes should cover. The council identifies nine key elements of note taking – I would like to highlight and remind readers of four of these:

  • 1d. information given to, and options discussed with, patients (and their family or whānau where appropriate)

  • 1e. decisions made and the reasons for them

  • 1f. consent given

  • 1g. requests or concerns discussed during the consultation.

These four items are particularly significant, as they provide you with your best defence against any future complaints.

Developing your own note-taking style and incorporating these aspects in the notes as and when appropriate will give you confidence. Listen to your instincts, for example if you felt the patient was not happy with your consultation, then consider making more comprehensive notes.

Note-taking takes time and this can cause pressure to make shortcuts. Developing a good structure and a mini checklist will help in this regard. For instance, General Practitioners often use the checklist acronym “SOAP “ meaning ; Subjective, Objective, Assessment, and Plan.

Perhaps you might develop your own, for example SOAPED: Subjective, Objective, Assessment, Plan, Education (handouts provided or copy and pasted hyperlinks to web sites recommended), Decisions (mutually agreed decisions, for instance discussed referring privately but the patient elected to go public).

No matter what system you choose to work with, it pays from time to time to read your notes and ask yourself: if there was a complaint and I opened this file would I be relieved or worried? Quality note taking remains one of the key tools in remaining risk-free.

Andrew Dunn, General Practitioner

In short: As we’ve written in a previous issue of Medicus Matters, self-prescribing or prescribing for those close to you is one of the ways that a clinician can find themselves seeking out defense support. The Medical Council has recently stated ongoing concerns about self-prescription in the doctor workforce.

There are several situations where the Council recommend never prescribing to either yourself or close family. Read their June 2022 guidance on self-prescription on their website.

Remember that your own health is as important as your patients’ – you should have your own GP too.


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