The clinical notes are a legal record. This means that you have a duty to record the events and decisions about a patient’s care faithfully. Also, you may be relying on the notes you make in the future in court, if you attend an inquest into a patient’s death, or if there is a complaint or claim from a patient.
There are minimum standards for the medical notes. Some of these are administrative, and irritating, but must be complied with.
Every page should have
The patient’s name
An identifying hospital number or NHS number
The Ward or location within the hospital
If these are missing, then that page may be ruled inadmissable in court, even though it may be obvious to you that the notes in question relate to a particular patient. Don’t be caught out!! Also, it will be noticed by your Consultant!
Every entry in the medical record should be dated, timed (24 hour clock), legible and signed by the person making the entry. The name and designation of the person making the entry should be legibly printed against their signature. Deletions and alterations should be countersigned, dated and timed
It takes ten seconds longer to write something legibly. It doesn’t look good in court if your writing is illegible. Get in the habit of taking a little more time to write legibly. It is worth it in the long run.
Entries to the medical record should be made as soon as possible after the event to be documented (e.g. change in clinical state, ward round, investigation) and before the relevant staff member goes off duty. If there is a delay, the time of the event and the delay should be recorded.
Every entry in the medical record should identify the most senior healthcare professional present (who is responsible for decision making) at the time the entry is made
An entry should be made in the medical record whenever a patient is seen by a doctor. When there is no entry in the hospital record for more than four (4) days for acute medical care or seven (7) days for long-stay continuing care, the next entry should explain why. Ideally, there should be an entry every day, and every time that a significant event takes place requiring review.
Advance Decisions to Refuse Treatment, Consent, Cardio-Pulmonary Resuscitation decisions must be clearly recorded in the medical record. In circumstances where the patient is not the decision maker, that person should
be identified e.g. Lasting Power of Attorney
Suggestions for Writing a Ward Round Note
On a ward round, you may be asked to write the record in the medical notes.
You should write down who the most senior decision maker is on the round eg WR Consultant, WR Reg, WR CT along with the date and time.
One way to organise a ward round note is to use the SOAP mnemonic
S SUBJECTIVE – ask how a patient feels in themselves, what they are complaining about, what has happened to them since the last time that they were seen
O OBJECTIVE – what parameters you can record eg early warning score, chest examination, urine output, blood results etc
A ASSESSMENT – what conclusions that you can draw from the above. This could be recorded as a problem list, either active or passive
P PLAN – how you are going to manage the issues on the problem list