All patients / clients who come into contact with a healthcare professional will have details of that contact documented in their clinical record (also called the medical record). These details are usually in the form of notes on the assessment, treatment, progress and ultimate plan for the patient and can be summarised in the SOAP format. Patient identification in the form of name, date of birth (DOB) and folder number on every sheet in the record is vital, as well as numbering each page consecutively.
Note: There is an important distinction to make between the information in the clinical record and the material on which it is stored. It implies that the information contained in the record belongs to the patient, but the paper it's written on belongs to the hospital or health professional. Thus, patients may take photocopies of the clinical record when they are discharged, but not the record itself.
Documentation should be clear and accurate for the following reasons:
- It promotes optimum patient care by providing a record of the baseline condition, treatments and progress.
- It ensures continuity of care.
- It allows communication between members of the Multidisciplinary team (MDT).
- It is a legal document that is admissible as evidence in court.
- It provides evidence of the care provided and decisions made.
If you make a mistake during the documentation process, draw a line through the incorrect entry and initial or sign it (some institutions require dating it as well). never use Tippex to obliterate an entry.
Abbreviations should be kept to a minimum, should only be used in the context of care and must only refer to the diagnosis, treatment and interventions carried out. They must be agreed and approved locally and therefore should not be used in transfer or discharge documentation.
If it's not documented, it didn't happen!
What constitutes a clinical record?
- Paper records including books, files, letters, loose papers, continuation sheets (or SOAP notes), diaries, post-it notes and computer printouts.
- Electromagnetic records including discs, servers and databases.
- Audio-visual records including films, tapes, videos and CDs.
- Photographs, maps, plans, X-Rays, microfiche and microfilms.
Principles of good documentation
- Write in chronological order.
- Record only factual information, not your opinion.
- Write legibly, printing if necessary.
- Use black pen, or print in black if the record is digital.
- Put patient quotes in quotation marks.
- Date all entries.
- Time all entries using the 24 hour clock (i.e. 18:00, not 6:00).
- Chart every intervention as soon as possible after the event.
- Chart notes should be neat and tidy.
- Sign each entry with a signature and position / role (e.g. Senior physiotherapist)
- Give the full name and title of all personnel mentioned in the record.
- Use only official Outcome Measures
- Test results must be signed and fixed to the proper mount sheet in the correct date order.
Digital medical records
The Electronic Health Record (EHR) and Electronic Medical Record (EMR) are standards that govern the technical specifications of how a patient's health information will be stored as the health industry moves increasingly into a digital environment.
- A guide to good clinical record keeping. Information leaflet for all healthcare professionals, Midland Health Board, Ireland.
- Electronic health record. (2009, January 4). In Wikipedia, The Free Encyclopedia. Retrieved 08:24, January 7, 2009, from http://en.wikipedia.org/w/index.php?title=Electronic_health_record&oldid=261840186
- Electronic medical record. (2008, December 31). In Wikipedia, The Free Encyclopedia. Retrieved 08:12, January 7, 2009, from http://en.wikipedia.org/w/index.php?title=Electronic_medical_record&oldid=261006644
- Gabard, D.L., Martin, M.W. (2003). Physical Therapy Ethics. FA Davis, Philadelphia. ISBN 0-8036-1046-7.
References will automatically be added here, see adding references tutorial.