A good medical record should be comprehensive and accessible, legible and pinned to a particular date. What you record may vary, but good note-taking plays a vital role. The main information should include:
Patient's History: as it applies to the condition and relevant past history including concurrent illnesses, medications and allergies.
Patient Examination: include positive and negative findings, and record all pertinent observations and measurements such as pulse, temperature, blood pressure.
Diagnosis: this must be recorded clearly and concisely, justifying how the conclusion was reached and record any uncertainties.
Investigations: This must include lab results and imaging such as X-rays or scans.
Management: record drugs prescribed and administered with dosage, and other treatments, such as physiotherapy.
Follow up and referral: include details of follow-up tests, future appointments and referrals.
Patient information: include details of discussions regarding risk-benefit, treatment plan, prognosis and potential complications.
Consent: record consent given, ensuring that it take into account the above.
If this sounds onerous, bear in mind that not all of these points are applicable to every consultation, or even every patient.
Forensically, good patient records answer fundamental questions like below:
Who?: All the notes in the record should identify the patient's subjective data like (name, date of birth, hospital number if relevant, address) and clearly identify the doctor making the note, along with a signature to verify this, in written records.
When?: Notes should include the date and time when a patient was seen or when a test or other procedure was undertaken or a treatment given. They should also note when the actual record or note was made if there has been a significant time lapse (hours or days - in which case, detail the reasons for delay).
What?: Record what was done, said, instructed, observed, checked.
Why?: It is vital to justify in the notes and the decisions taken with regard to patient care.
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