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GOOD MEDICAL RECORDS,'' Worth their Weight in Gold''
Record
what you have seen ; make a note at the time; do not wait.
- Sir William Osler
Most of
doctors do not have habit of paper work-especially that involved in
entering information in medical records .Thus, while most surgeons
enjoy operating ,many treat documenting the medical details in the
record as a painful chore which they would rather not to . This often
means that entering data into the medical chart is delegated to a
junior or inexperienced assistant , as a result of which it is
often not done well.
Remember that the medical record servers many purposes,
and its primary function is to plan for patient care. However, from
the risk management perspective, the medical record is a crucial
element in preventing and minimizing malpractice litigation .
Ultimately , it servers as the basic for the defense of malpractice
claims and lawsuits. Medical records which are poorly maintained ,
incomplete , inaccurate, illegible or altered , create doubt about the
treatment given to a patient , and can be a major medical legal
liability. By contrast , proper documentation in the medical record
creates a legal document which accurately and completely reflects the
care provided to patient and , in a courtroom setting , it may be
likened to a witness whose memory is never lost.
While keeping good records is simply a matter of common
sense the mnemonic OLFACTORY, which stands for- original , legible,
factual, accurate compete, timely, objective, rationale and yours-
will help you to define 'good' medical record.
It is help to follow as system when making notes in the
medical record to ensure that all important information has been
recorded. The SOAP system (which stands for Subjective the patients
history), Objectives (examination findings), Assessment and plan) is
popular in many hospitals , and is easy to implement . Preprinted
medical records can help to establish consistent documentation ,
ensuring you do not forget to record important information . They can
also help to save your time when entering data.
When writing orders in the chart, it can be helpful to
remember that following headings (the mnemonic being ADCA VAN DILMS)
to ensure that important orders are not overlooked . Every doctor
should develop his/her own systematic method to ensure completeness. |
