Keeping the record straight

HPCSA registered practitioners are advised to adhere to the following guidelines on record keeping that will also improve clinical outcomes, reduce waste, and ensure stakeholder engagement and satisfaction.

Basic patient information requirements:

  1. Personal (identifying) particulars of the patient.
  2. Bio-psychosocial history including allergies and idiosyncrasies.
  3. Time, date and place of every consultation.
  4. Assessment of the patient’s condition.
  5. Proposed clinical management of the patient.
  6. Medication and dosage prescribed.
  7. Details of referrals to specialists, (if any).
  8. Patient’s reaction to treatment or medication, including adverse effects.
  9. Test results.
  10. Imaging investigation results.
  11. Information on the times that the patient was booked off from work and the relevant reasons.
  12. Written proof of informed consent.

Time constraints and patient care can complicate accurate documentation – a practitioner may treat the patient with the best intentions but only lacks the records to rely on in the event of a complaint or legal case.

Protocols:

  • Develop a system that will streamline the process and alleviate the pressure of having to record absolutely everything. Standardise and try to automate documents as far as possible – with the first form completed by the patient while sitting in the rooms during the consultation.
  • Once the identifying particulars and biopsychosocial history has been obtained, the patient’s current medical status should be recorded during each visit.
  • The detail and accuracy is important in the event of the treating practitioner, or another medical practitioner, needing to refer back to the notes at a later stage to understand the patient’s medical history.

Legibility

Another issue of concern, especially in a court of law, is that of illegible handwriting. Again, pressed for time, the practitioner writes faster with resulting deterioration in handwriting.

With records being important in complaints and lawsuits, poor handwriting puts practitioners at risk.

A practical way to overcome this is with the aid of technology. A patient’s consent can be obtained to record the consultation on a recording device.

Thereafter, the recording can be typed up by a staff member in the practice. This can be used to augment and support the notes the practitioner is still required to take during the consultation. The process of the voice recording and subsequent transcript will make record keeping easier and legible.

Consent

An informed consent form can go a long away in assisting a practitioner to prove what the patient was aware of, in and during the consultation.

An informed consent form will also assist in showing that a patient was made aware of the aspects of their treatment. A court of law takes cognisance of the documents signed by a patient when they allege that they were not made aware of aspects of their treatment. The most practical answer is to have standardised forms developed specifically for your practice which cover the procedures that patients will undergo. On signing these forms; patients acknowledge that they have read and understood the contents of the informed consent, thereby protecting the practitioner and focusing the patient’s attention on ensuring that they really do understand their treatment.