Patient records – what should they include?

The Osteopathic Practice Standard C2 has a list of what must be included in patient records there are 15 items. I recommend you look through and see if there is anything that you are not routinely including in your notes. This is a list you should return to periodically because it is a prompt for you to maintain the standard of your notes, over time it is easy for things to slip and to get out of routine of including one element.

As an example I’ll just highlight a few elements:

Do you record how information and advice is provided or communicated to patients? (1.6)

Do you always include a treatment plan? (1.7)

Do you make sure email conversations are added to the patient record? (1.10)

Do you record who observers or other persons present are? (1.15)

There are other standards pertinent to the content of your patient records – standard A4 on consent, A6 on chaperones (you should record that a chaperone was offered in particular circumstances), C1 you must record the location of the treatment if not in your usual clinic, D5 disclosure of confidential information, D9 hand over of patients.

Your record of consent is extremely important. You need to refer back to A4 (18) to see the details of what is required. You must record your discussion – what you informed patients about, any response from the patient or concerns, how they were dealt with and any decisions made.

One of the frequent criticisms of practitioners in fitness to practice proceedings is poor patient records. Remember the legal rule is: If you did not write it down, it did not happen.

Have a good system

I’ve already emphasised the importance of your patient record for continuity of care and legal reasons. Making sure you have consistent systems for your patient records will help you to include all the necessary content to ensure quality of continued care and all information needed should any issues arise.

Make sure your clinic notes are completed as soon as possible after the appointment, it is very easy to forget exactly what happened, overlook important details or even get muddled with subsequent patients.

Whether you use paper notes or electronic you should have systems in place that make it easy for you to comply. There should be space for all the information required and prompts if necessary. You should have systems for recording email and telephone conversations. If you are in a multi-practitioner practice it is helpful to have consistent systems within the practice.

The art of patient records

There is an art to making a good patient history form. It needs to allow you to have the flexibility to follow the patient’s conversation and yet have the constraints to make sure you cover the fundamentals. Your quality of care will be reduced if you turn your patient record into a tick box exercise or a questionnaire format that you work through. Each patient wants to be listened to as an individual and to have the freedom to tell there story.

This might be an opportunity for you to spend some CPD time reviewing your patient record forms against the criteria. It would also be helpful to audit some completed records. Even if the appropriate prompts and systems are there you need to check they are routinely being used.

Your records represent you

Make your patient records another aspect of your practice that represents your high standards of practice and the quality of care you aim for. If someone asks to see their notes or you need to share them or pass them on wouldn’t it be a great asset for your practice if you had no fear but felt you could confidently pass on your patient record and that it represented the standards of your practice.

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