Accurate note-keeping is a fundamental aspect of a Junior Doctor's responsibilities. While it may seem tedious at times, meticulous medical paperwork can have a significant impact, especially in the event of adverse incidents or legal proceedings. Effective communication through clear and concise notes is essential as doctors interact with various individuals using forms and documentation. In this blog post, we will explore the significance of accurate note keeping and provide valuable tips for maintaining comprehensive and legally sound patient records.

The Art of Clear and Legible Patient Notes

Writing clear and legible patient notes is the cornerstone of effective medical documentation. When using electronic notes (electronic patient record or EPR), accurate typing becomes crucial. When starting at a new hospital, seek guidance from your predecessors regarding any computer shortcuts or favourite lists used for blood requests. Familiarise yourself with the specific features and functionalities of your hospital’s EPR.

Regular and Timely Documentation

While doctors are expected to write in patients' notes at least once every 72 hours, it is considered good practice to document something daily. Delayed documentation increases the likelihood of forgetting crucial details discussed with patients. It is advisable to write in the notes as you go along, or if working with a colleague, have them scribe while you conduct Ward Rounds.

Key Aspects of Patient Notes

When documenting patient notes, keep the following points in mind:

• Always sign notes with your signature (if your hospital still uses paper notes) and clearly print your surname, along with your level and bleep number. Some hospitals provide stamps for this purpose. If you make any corrections, cross-outs, or amendments, ensure to initial or sign your name beside them.

• Ask yourself two important questions: Do the notes contain enough information to treat the patient in your absence? Will these notes provide legal coverage if presented in court?

• For daily notes, consider using standardised methods like SOAP (Subjective, Objective, Assessment, Plan).

• The plan section is crucial in any note entry. Include details such as scheduled scans, tests, or any actions that need to be taken. This ensures that all of your colleagues as well as the wider MDT have access to key information on the patient’s management.

• If uncertain about documenting a patient's condition, refer to previous notes to understand how others approached similar situations - with time you’ll develop your own documentation style!

• Always include the time and date in the margin of the notes. When documenting a Ward Round, note the surname and designation of the person leading the round at the top of your entry.

Documenting Patient Encounters

When called to see a patient, briefly document the following, even if the call was seemingly trivial:

• Acknowledge that you saw the patient.

• Record the time and date.

• State what the concern was, provide your assessment and give your plan of action (even if it aligns with the current treatment plan).

Professionalism and Objectivity

Remember that patients and their relatives have legal access to their medical notes should they decide to fild a Subject Access Request (SAR). Maintain objectivity in your documentation, avoiding emotional biases. This is particularly important during discussions about DNACPR orders or advanced care planning. Use quotation marks when capturing direct patient or relative statements if it enhances the accuracy of the documentation.

Be Diligent and Seek Guidance

It is acceptable to document "no change" if there have been no significant developments in the patient's condition. However, ensure that you haven't missed any important changes. If you are unsure about appropriate changes to make, it is better to consult your seniors earlier in the day rather than later. Some Consultants or Registrars conduct "Board Rounds" where they go through the patient list and discuss in brief each patient’s situation and management plan and if anything has changed from the morning’s Ward Round. Use this opportunity to clarify any changes they recommend so that you can prioritise your tasks effectively.

Consider Social and Psychological Aspects

Don't overlook the importance of documenting the social or psychological aspects of patient care. Note the patient's emotional state, whether they are cheerful, sad, or experiencing other emotional challenges.

Conclusion

Accurate note keeping is an essential skill for all Doctors that cannot be underestimated. By maintaining comprehensive and precise patient records, you not only enhance patient care but also ensure legal protection for yourself and your healthcare institution. Take pride in your documentation skills, follow best practices, and remember that effective communication through clear and accurate notes is key to providing optimal medical care.

by Dr Ahmed Kazie