Documentation should summarize, but needn’t be exhaustive
Documenting a patient encounter, whether into a paper or electronic medical record, is integral to the delivery of safe, high-quality care. It facilitates good care by keeping a record of patients’ care and general health information, allowing the treating physician and other caregivers to understand patients’ conditions and the reasons for certain investigations or treatments, providing a means of communicating with other care team members, and satisfying the legal and professional requirements of legislation, medical regulatory authorities (Colleges), hospitals, and courts.
Because medical records also serve as legal documents, properly constructed records that are created contemporaneously (at the time of the encounter or as close to it as possible) may help physicians recall details, specifically when used as evidence in a legal action or when responding to a College complaint.
Clinical notes do not have to be exhaustive, yet must provide an adequate summary of the clinical situation and physicians’ thought processes leading to a diagnosis and plan of care. The following information is important to consider when documenting clinical care:
- clinical assessment
- conclusions including working, differential, and final diagnoses
- the rationale for plans of action such as investigations, treatments, and consultations
- information exchanges with patients and families including discussions, decisions, apparent understanding, and consent
- discharge instructions and follow-up care
A medical record can be corrected; however it must be done appropriately in accordance with provincial and territorial standards.