Making clinical notes
eRecord systems typically include template texts that help to standardize how information is presented and save time for physicians. However, such templates may also reduce the personalized nature of clinical notes and thus affect their perceived credibility.
- When writing clinical notes, strive to demonstrate the personalized approach to care for each patient.
- Document only factual information discussed and actions taken, avoiding a “click all” that may not apply.
- Pay attention to pre-populated fields and ensure you are using the proper templates.
- Use free text, where appropriate, to personalize the note for each patient.
Corrections and edits
Physicians have a responsibility to respond to requests from patients seeking a correction or amendment to their eRecord. Physicians are generally entitled to refuse requests to correct medical opinions or information that is necessary for clinical purposes. The decision to comply or decline a patient’s request must be made on a case-by-case basis and in keeping with applicable privacy legislation or College requirements.
Physicians also have a general duty to correct inaccurate information in a patient’s record, especially when the information is vital to the patient’s treatment. If physicians become aware that an eRecord to which they have access contains outdated, incomplete, or inaccurate information of clinical significance, it is prudent to alert other users within a reasonable time so the patient’s treatment is not compromised. Then, physicians should try to correct the erroneous information as soon as possible. Privacy legislation generally requires custodians who correct records to notify others to whom the relevant information has been disclosed.
If a doctor believes the record must be changed, as much as possible the amendment should be made in accordance with applicable College requirements. It should not obscure or delete the original entry. Changes can usually be made using an addendum or digital strikeout. The date, time, and initials (or electronic signature) of the person making the alteration should be visible on the electronic record. A “track changes” function may be used. When this is not available, an addendum should be placed in the record explaining what change is needed, preferably next to the original entry, if possible.