10 FYi


• Record keeping


Trainee doctors play a key role in hospital record keeping. FYi editor Dr Naeem Nazem offers practical advice on avoiding common pitfalls


KEEP THE RECORD W


HETHER it is recording your interaction with a new patient, documenting a ward round or assessing a patient individually, trainee doctors’ clinical entries form the


cornerstone of the medical records for most patients in the hospital. You may not be at the top of the clinical pecking order but your role is critical in ensuring the wider healthcare team is aware of the ongoing management of each patient and delivers effective care. While your schedule is most likely hectic


with barely a chance to stop for a bite to eat, taking time to keep clear and comprehensive notes is crucial. Here are some common risk areas to look out for.


Keep it legible Most doctors have reviewed medical records containing hard-to-decipher scrawled handwriting. Or perhaps they are littered with abbreviations you have never seen before which could have multiple meanings. Entries like these are unhelpful and potentially harmful to the patient if misinterpreted. Next time you come across one, try to identify the author and seek


clarification from them. Alternatively, ask a colleague to review it with you and always consider if what you believe is written would be clinically appropriate for that patient. It is all too easy during a busy shift to follow a documented action plan blindly. MDDUS recently dealt with a case in which a


patient was inadvertently prescribed 10 times the suggested warfarin dosage by an FY doctor who had misread a medical entry and didn’t notice the previously prescribed doses. Fortunately the error was detected in time by the nursing staff. If you are writing in a medical record, think


about how easy it will be for other healthcare professionals (doctors, nurses, pharmacists etc) to read and understand. Patients may also request access, so keep your entry objective and professional. One FY doctor found themselves in an embarrassing situation after they were asked by a patient to explain a written note stating that he was “a nightmare”. MDDUS has also encountered several cases in which nursing staff have misread an FY doctor’s prescription, resulting in a medication error. This often occurs when a doctor has attempted to write a new dosage on top of the original entry, rather than rewriting it entirely.


It is also worthwhile to keep in mind that


your medical entry may be reviewed many years down the line. For example, a patient may make a claim of negligence or there may be an investigation into an alleged misdiagnosis. It is therefore really helpful if you can print your name after you sign your medical entry and ideally include your GMC number. Many doctors carry a stamp with their name and GMC details as a useful timesaver. Although not essential, try to make your


entry in black ink. This is less likely to fade over time and is also easier to read if the records are photocopied.


Keep it accurate Remember the medical record you make is sometimes the only available reflection of your actions and rationale. You should therefore take care to ensure that your entry is clear and unambiguous. MDDUS recently dealt with a case in which a junior doctor was asked out-of-hours if a drain could be removed from a post- operative patient. The patient himself said he was told during the ward round that it could come out. The doctor reviewed the medical records and could only find a “tick” next to


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