Why Is Accuracy in Documenting Patients Record So Essential

Patient documentation is not only a legal requirement but forms part of good practice and the process of keeping patients safe. Although both the medical and nursing professions have guidance in patient documentation, in practice medical notes are often imprecise and incomplete. It is not until there is a mishap involving the patient leading to litigation that practitioners realise the importance of full and accurate note-taking.

As an experienced nurse working with lawyers, I am finding that there are some pitfalls which can be avoided offer three examples.

Incomplete tasking

This occurs when the practitioner fails to describe why the patient has returned following, for instance, an adverse event. A summary of the discussion to deal with it and any action taken should be recorded. Referral to a colleague should also be noted. An example of incomplete tasking would be ‘patient reassured’ without any explanation of what has gone on before. On its own, it is a meaningless term that the patient can challenge.

Lack of precision in communication

Practitioners need to be objective in their recording of events. This is not something that the caring professions do well and there is room for further training in this regard. However lawyers and expert witnesses rely heavily on the notes and if the facts are not recorded clearly and unambiguously, the defendant in a claim against them may be vulnerable.

The danger of misinterpretation

Overall patients are much more medically literate – they use search engines on the internet and read about health issues in the media. Not all the information is accurate. As practitioners, we have a responsibility to ensure patients are given accurate facts about their treatment and understand what is involved. There is no legal test for understanding as much depends on the language used and how information is presented. However, practitioners can ask the patient to reflect back to them what they have been told in order to demonstrate clarity.

What can the legal profession do to help?

There is room for the medical and legal professions to work together in addressing potential pitfalls and avoiding litigation. By its very nature litigation is adversarial and for many practitioners, their first contact with the law is when something goes wrong. Although ignorance is no defence, an understanding of changing and evolving case law can help provide a rationale for legal requirements. See also blogs on both Bolam and Montgomery.

To conclude

Accurate and precise documentation is a professional and legal duty of care. Danger areas include incomplete note-taking, lack of objectivity, and misinterpretation of information. There is scope for the legal and caring professions to work together in order to try and reduce the incidence of litigation.