Good medical record keeping (7 top tips)

Good medical record keeping (7 top tips)

1. Write legibly; sign legibly – with your name, rank and number (how will the next person know how to contact you?)
2. Include details – of the patient, date, and time
3. Record them soon after a patient contact, preferably now – as you need to get across the tone and emotion of the contact, not just the information
4. Avoid abbreviations – and unnecessary comments
5. Do not alter an entry or disguise an addition – it is a medicolegal document
6. Check dictated letters – and don’t copy to people unnecessarily (it will reduce their focus in more important information)
7. Data Protection Act 2018 – be familiar with it. Everyone responsible for using personal data has to follow strict rules called ‘data protection principles’. They must make sure the information is a. used fairly and lawfully, and b. used for specified, explicit purposes. And you should only look at information about the patient that is relevant to you, if you currently caring for the patient.

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Medical record keeping