Record Keeping - Reasons for Legitimate Documentation and Record Keeping

REASONS FOR LEGITIMATE DOCUMENTATION AND RECORD KEEPING IN HEALTH CARE

Despite the importance of clinical record keeping and documentation, it is often given low priority. It can be common practice to find illegible entries, offensive comments, missing information and inconsistencies between entries by different health care professionals.

If the records are unclear, inaccurate or written in such a way that they’re difficult to follow, it could cause errors and misunderstandings (medicalprotection.org).

Please see examples below of the advantages of keeping good clinical records and the disadvantages of poor clinical records:

GOOD CLINICAL RECORDS

Aid the sharing of relevant information and multidisciplinary team communication

Aid coordination of care

Aid continuity of care

Aid informed decision making for patient management

Improve availability of data for risk assessment

Improve availability of data for route cause analysis in the investigation of serious incidents

Improve audit capabilities

Provide informative evidence in a court of law

Aid targeting of diagnostics and treatment plans without unnecessary repetition

Improve time management

POOR CLINICAL RECORDS

Misinform healthcare professionals and patients

Increase medico-legal risks

Lead to unnecessary repetition of tests or other investigations

Prolong hospital admission

Jeopardise patient care

Lead to serious incidents

Mathioudakis, Rousalova, and Gagnat et al (2016)