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Good notes vs bad notes
An article for physicians by physicians
Originally published January 2000 / Revised April 2008
IS0011-E

Of interest to physicians dealing directly with patients

Time and again the CMPA has reminded its members that good notes contribute greatly to the successful defence of a legal action or response to a College complaint. A prompt and successful resolution of medico-legal difficulties is made easier by high quality notes.

What constitutes good notes? How do they differ from bad? Here are a few of the characteristics.

Good Notes...

... are legible

A major purpose of notes is to communicate with subsequent physicians or other health care workers. Illegible notes not only make it difficult to follow up on care, but can be interpreted by courts or regulatory authorities (Colleges) as evidence of haste or lack of care. This interpretation may be unfair, but it is a real possibility.

... are made at the time of contact

Notes made at the time of the contact, whether it is by telephone or in person, will generally be viewed as more accurate than recollections by either the doctor or the patient at a later date, after the outcome is known.

The CMPA offers useful telephone record pads that can be kept by your telephones or in your pocket.*

... are objective

Facts should be carefully recorded – for example, "The patient says that someone deliberately tripped him..." is much more accurate than, "The patient was deliberately tripped," unless you observed the event. Similarly, "This person smells of alcohol and has an abnormal gait" is better than "This person is drunk." Inferences and assumptions should be avoided, or at least clearly indicated as such.

... demonstrate the thought process

The symptoms, physical findings and laboratory results on which you based your plan of care should be identified, so it will be apparent your plan of care is a clear and logical result.

... indicate information given to the patient and the patient's response

• Informed consent to any treatment, whether surgical, medical or psychiatric, requires that alternative approaches, risks, benefits, side effects, etc., be discussed. Good notes demonstrate this has occurred.
• Any questions asked by the patient and the answers given are listed.
• Information given to the patient about future plans, such as follow-up visits and what the patient might expect is also indicated.

Bad notes...

... may show notations awkwardly squeezed in

This may give the appearance of being added later, casting doubt on their reliability.

... often fail to follow chronologically

This may create the perception the doctor was disorganized or unaware of information available from previous encounters.

... may have whited-out or blacked-out areas

Again, these may cast doubt on reliability.

... often have gratuitous comments about the patient's character, intelligence or appearance

These may make the doctor appear to lack objectivity.

The bottom line

In summary, good notes clearly document the facts of the situation. Bad notes, on the other hand, are open to misinterpretation or are simply unhelpful either in providing care to the patient or in demonstrating what took place.

* CMPA telephone record pads are available in bundles of 20 English or French pads. Call 1 800 267-6522 and have your CMPA member number handy.