10 keys to good patient-centred record keeping

Dr Walid Jammal

The conversation with my new registrar goes something like this: I deliver my lecture about the importance of good record-keeping and put on my medico-legal hat to tell her that the primary purpose of this is to ensure patient safety and continuity of care.

I explain that keeping adequate records is also critical to avoiding claims and complaints, and enabling her to justify her Medicare billings.

And she responds: “But you just told me I need to be focused on the patient and that communicating clearly with the patient is the key. So which is it?”

It is a fair question, and one I’ve spent a bit of time thinking about.

I stand by both pieces of advice.

However I recognise the challenges inherent in balancing the need to keep good records, without allowing the process of record-keeping to get in the way of the patient interaction.

What must a patient record contain?

The expected standard of medical notes is addressed in Good Medical Practice: A Code of Conduct for Doctors in Australia (the Code) (section 8.4), which outlines the standard of record-keeping the Medical Board has set down for good medical practice.

If your records are ever called into question, the regulators will be looking to the requirements of the Code, state regulations such as the Health Practitioner Regulation (New South Wales) Regulation 2016, any specific documentation required to meet Medicare item number descriptors, and to the opinion of expert peers.

The rule of thumb I still find most useful is that records need to contain enough information to allow another practitioner to take over the care of the patient.

When you are making notes, think about what you would want to know from the records if you were taking over the patient’s care and hadn’t spoken to the previous doctor.

When doing so, you may also find it important to outline your clinical reasoning.

Records should be legible, contemporaneous and contain:

  • the history obtained from the patient, including positive and negative features 
  • your examination findings, including both positive and negative findings that impact upon the differential diagnosis 
  • the provisional diagnosis reached
  • any differential diagnosis considered
  • the management plan, including the options discussed with the patient, the treatment recommended, prescriptions given and tests ordered, and
  • information provided and the patient’s consent to any treatments.

Many people like the acronym SOAPIF as a prompt to make sure they have captured key information:

  • Subjective –information the patient (or others) provide to you
  • Objective – what you find on examination or on pathology or imaging
  • Assessment – your complete diagnostic formulation
  • Plan – total management plan
  • Information – information you provide to the patient
  • Follow-up – note the agreed plan, including the specific circumstances that would trigger follow up.

Balancing record-keeping and communication

I have developed a number of techniques over the years to get the balance right.

As GPs, many of us are already aware of the various strategies used to combine good record keeping and good communication, like always starting with the focus on the patient, and not the computer.

This allows the patient to outline and expand on their agenda without interruption.

Another useful way of engaging with the patient is to make the computer screen part of the consultation.

One way is to put the screen flat on the wall so that both the patient and you can look at it – making the note-taking part of the consultation.

This is also a good way to keep front of mind that you should never write in the notes anything you wouldn’t want the patient, or anyone else, to see.

Failing that, positioning monitors so they are not between you and the patient can be useful. Make sure you don’t turn your back on the patient to look at the monitor.

Explaining to the patient what you are doing can help to keep the focus on them.

Think about ways you can combine documentation with communication. For example if you provide the patient with written information, diagrams and the like to take home, this can help support the verbal advice you have already provided during the consultation.

Keep a copy of the information you provided on file as part of the record and note when it was provided to the patient.

Also, record any advice or warnings you routinely provide. You can use software to your advantage here. Make use of shortcuts or macros for anything you regularly need to record. These can also serve as prompts to ensure you have actually conducted these routine checks.

But use them carefully, make sure you amend the content to record what you actually did, said, and observed.

Avoid cutting and pasting from previous records so that you don’t paste in irrelevant or inaccurate information.

Finally, you can consider using medical records as an education and improvement tool within your practice.

One way of testing the adequacy of your records is to have someone in your team periodically provide a case review on the basis of your notes.

Key tips:

  1. The record should contain the information you would need if you were taking over care of the patient.
  2. Always assume someone else (including the patient) may see the record.
  3. Remember the minimum standards: history, examination, diagnosis (provisional and differential), management plan, information provided, consent.
  4. Make sure you document advice or information you routinely provide.
  5. Wherever practical, document your clinical reasoning and why you reached a certain diagnosis, performed a test, or prescribed a drug.
  6. Use shortcuts and macros to speed up note-taking and to serve as a prompt. But be sure to customise your notes to the patient’s circumstances.
  7. Avoid the cut and paste function.
  8. Explain to the patient what you are doing, and involve them in their record. 
  9. Think about room layout to better include the patient in the note-taking.
  10. Use patient records as a teaching tool, eg. case reviews or team audits

 

Dr Walid Jammal is a General Practitioner and Senior Medical Adviser - Advocacy at Avant. This article first appeared in Medical Observer 15 January 2018. Click here to read the original and other similar articles https://www.medicalobserver.com.au/professional-news/10-keys-to-good-patient-centred-record-keeping

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Never write anything in your notes you wouldn't want the patient, or anyone else, to see.