Clinical records are made-up of a broad range of material, including, but not limited to: clinical notes (electronic and/or handwritten notes); correspondence between health professionals regarding patients’ care; laboratory reports; imaging and radiology records; data produced by monitoring equipment; models/molds; photographs; video and audio recordings.
Why are clinical records so important?
Clinical records are essential for the continuance of good patient care.
Clinical records are also essential in assisting a health practitioner in defending a claim or complaint.
The quality of a health practitioner’s records can be seen to reflect the quality of care provided.
Maintaining appropriate records is recognised as an important aspect of patient care and a health practitioner’s professional obligations. Failing to maintain adequate clinical record keeping may amount to a breach of professional standards and result in an adverse finding by a health practitioners’ professional regulator.
What should clinical notes contain?
Clinical notes should contain sufficient detail to enable another practitioner to take over the care of the patient, if necessary.
Clinical notes should be concise, accurate and up-to-date, and contain information relevant to the patient’s condition and treatment, including but not limited to: clinical history; clinical findings; investigations and results; medications; treatment planning; information provided and discussed; consent and referrals; and treating practitioner’s name.
When should a health practitioner make clinical notes?
Clinical notes should be made at the time the consultation takes place or as soon as practicable afterwards.
A health practitioner forgot to include something in the clinical notes. Can a health practitioner go back and add information?
If a health practitioner later realises that the clinical notes they have prepared are factually inaccurate, they may add an amendment, however, do not remove information. Any amendment must be clearly shown as an alteration, complete with the date the amendment was made, and the health practitioner’s name.