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ENGLISH FOR DOCTORS

Lesson 19
MEDICAL RECORDS

Writing good medical records


Medical notes should allow another medical professional to reconstruct your consultations with the patient, bearing in mind that it is likely that the patient, their relatives or representative will read the notes in the future.

Notes should include: History relevant to the condition, including any answers to direct questions. Examination of the patient any important findings, both positive and negative, and details of any objective measurements, such as blood pressure.

Diagnosis it should be clear from your notes how you arrived at this conclusion. Include any uncertainties about diagnosis, and steps taken to rule these out. Detail any further investigations you have arranged.

Information what you have told the patient, including any details of the risks and benefits of particular treatments. Consent details of any consent the patient has given, together with the background of any discussion that led up to that consent.

Treatment detail the type and dosage of drugs, the total amount prescribed and any other treatment you have organised. Follow-up include the arrangements for following up tests, future appointments and any referrals made.

It is not only the content that is important, but the way that notes are presented. You should ensure that they are: Clear identify the patient clearly. For written notes, write legibly in black ink. If you cant write legibly, type your notes or have them typed. Sign each entry with a date and time. Be careful with abbreviations.

Objective opinions should be based on the facts you have recorded. Contemporary write notes up as soon as possible after an event. First-hand if information has been given to you by anyone but the patient, record that persons name and position, eg, a relative, friend, translator, ambulance staff or police.

Tamper-proof any attempt to amend records should be immediately apparent, eg, notes should always be written in pen, not pencil. Computer systems should record the date and author of any notes, and track any amendments.

Original implied by the last point, medical records should not be altered, or amended without suitable annotation. The National Hospitals Office Ireland Code of Practice for Medical Records Management (2007) states: Deletions or alterations shall be made by scoring out with a single line followed by the date and time of the correct entry and the reason for the amendment.

Abbreviations
Using abbreviations saves time, but can lead to problems. Abbreviations should be unambiguous and universally understood. This is particularly true in general practice, where a patient may have unrelated conditions with shared abbreviations.

Certain abbreviations are unacceptable, such as coded expressions of sarcasm, or humorous abbreviations to describe a patients condition. The National Hospitals Office states that abbreviations should not be used on consent forms, death certificates, incident report forms and communications sent from the hospital.

Tips when starting at a new practice


Many practices will provide you with an induction pack or arrange an induction day, which will, among other things, cover how records are organised. Here are some questions that it is worth finding out the answers to. It will help to make your first days in the practice run smoothly.

Computer records How does the system work? How are user names and passwords arranged, and how often are they changed? Paper records How are records filed? How are records signed in and out? How are they kept secure?

Abbreviations What abbreviations are acceptable and commonly used (eg, other members of staff, local clinics and hospitals)? Tests How are they ordered and how is this noted in the records? How are late tests followed up?

Results How do they come back? How will you be notified that results need to be reviewed? How are the results filed?

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