Clinical record keeping is evidence of good professional practice and the delivery of quality healthcare. Every patient that visits your clinic will have a patient record. Have you ever thought about the importance of your patient records?
You might just answer – because we have to keep records as one of the standards of being called an osteopath. For all registered health professionals there is a legal requirement to keep patient records but beyond this, what is the reason for making sure your patient records are high quality:
There are three key reasons for keeping good patient records:
- Continuity of care
- Legal purposes for patients – e.g. insurance claims
- Legal purposes for practitioners – e.g. defending a complaint
“Your patient records should be sufficient to enable you or someone else to reconstruct the essential parts of each patient contact without reference to memory.” Medical Protection Society.
Continuity of care
Osteopaths strive to provide best quality care for patients. Having good patient records will enable you to follow up on symptoms, have an accurate record of the care plan agreed with patients and the consent process used. You will be able to return to the record to follow-up on symptoms, to review the treatment plan, to understand what treatment was used and whether it was effective, to recall the self-help advice the patient was given. Having accurate records helps you to provide quality care. I’m going to mention 4 simple examples but I am sure you could come up with many more:
- It’s not uncommon to ask a patient about a symptom they had mentioned such as tingling in their hand and when you follow-up at a subsequent visit it is something they had completely forgotten about.
- If a patient mentions an ongoing symptom such as swollen feet you will have a record that they had the same symptom 1 month ago, which a patient may well have forgotten.
- Your records will give you prompts about psychosocial symptoms so you can continue conversations and support in this area in a way that the patient feels valued, and supported rather than keep going over the same information and the patient feeling that aspect of care is less relevant.
- Having a record of the self-help actions agreed with the patient enables you to follow-up on compliance and also progress exercises appropriately
That highlights the importance of your patient records for your own continuity of care for patients but what about when your patient sees other professionals.
Continuity of care for colleagues
Good patient records will assist colleagues in providing good continuity of care. It can be a source of patient dissatisfaction if they see another health practitioner but it is obvious that there are large gaps in their knowledge about previous care provided due to inadequate patient records.
Perhaps you work alone and think that continuity of care is less applicable. You never know when a situation may arise where a colleague has to access your notes. Maybe you will have an associate one day. If you had a long-term period of ill-health perhaps you might bring in someone to cover the clinic. Maybe patients will request their records to be passed on when they move house and change practitioner. You never know how continuity of care might arise.
Your records may also be passed on to other healthcare professionals or as part of insurance claim and therefore provide a representation of the quality of care and standards in your practice. Would you be embarrassed or pleased to share your patient record?
Your patient records need to be sufficiently detailed to provide robust representation for either your patient or you. They may be the evidence for a patient making an insurance claim or the evidence for your defence if a complaint arises. This is a secondary, but important, motivation for making sure you keep good patient records.
I hope this has stimulated your thoughts to feel more committed to the value of good patient records. Next week we will consider the content of your records in relation to language in more detail.