Avoid abbreviations

What does PND mean - post-nasal drip or paroxysmal nocturnal dyspnoea? It may be clear to the author but could be ambiguous to others reading the records at a later date. Use abbreviations with care.

Be nice

Never use derogatory and offensive comments. Not only is this highly unprofessional, but patients and others have a right to access their notes under the Data Protection Act. Be respectful, as your records could be seen by colleagues, patients, their families…and their lawyers.

Include date and time

This is particularly important from a medico-legal perspective, as a claim could be brought by a patient years after the event. Memories fade with time and you may not be able to recall exactly when you treated someone or were involved in their care.

Never tamper with notes

This has led to GMC investigations. Never try to hide errors or disguise additions. As a general rule, errors should be crossed out with a single line so the original text is still legible and the corrected entry written alongside with the date, time and your signature. New additions should be separately dated, timed and signed by the doctor who made them.

Never try to insert new notes, regardless of the format. While it might appear easy to alter digital records, computerised systems have an audit trail that will allow changes to be discovered.

Check dictations

Typed and dictated notes have the advantage of being clearer, but you should make sure no errors have accidentally crept in during the process. They should be checked, corrected and signed by the doctor who dictated them.

Finally, it's a good idea to be familiar with the Data Protection Act 1998. This act allows patients to view their records or receive a copy of them, subject to some exceptions.

Notes on notes - advice on writing good medical records

Dr Shelagh Turvill

Notes on notes - advice on writing good medical records