Whether in written or electronic form, medical records are central to patient care and safety. Clear and legible records satisfy legal, professional, institutional, and ethical obligations. The records act as evidence if your care is later questioned. Your provincial medical regulatory authority (College) may have specific guidelines on what it expects from documentation.
Other than serving as a permanent record of the care provided, good documentation also:
Good practice guidance
Every care provider is responsible for documenting the care and recommendations they have provided.
This can be delegated to an assigned recorder (for example, during an emergency resuscitation), but it is wise to confirm the accuracy of the record as soon as reasonably possible. Some centres employ medical scribes to allow physicians to focus on and facilitate the interpersonal nature of care. You should be familiar with your College’s policies concerning scribes.
A good note should allow a subsequent reader to place themselves in your shoes and understand your diagnostic reasoning, your justification for excluding other diagnoses, and your reasons for proceeding as you did. Clinical notes do not need to be exhaustive, but should give an adequate picture of the clinical situation.
Clinical notes generally include the following:
- patient, source of the information, date and time, identity of the interpreter or substitute decision-maker (if used)
- relevant history and physical findings
- vital signs
- pertinent positive/negative findings as well as the presence or absence of any red flags
- assessment of patient capacity (if appropriate)
- clinical assessment
- working, differential, and final diagnosis
- plan of action
- investigations, consultations, treatment, follow-up
- rationale for the plan
- expectations of outcomes, including uncertainty (if appropriate)
- doses and duration of medications
- elements supporting medication reconciliation
- calls to consultants
- consultant's name
- advice received
- information given by or to the patient (or substitute decision-maker [SDM])
- concerns raised, questions asked, and responses given
- verification of patient understanding
- consent discussion summary: patient’s choice of action including not receiving treatment or treatment refusal
- discharge instructions
- symptoms and signs that should prompt a reassessment
- urgency of follow up
- where and when to return
- missed appointments
- efforts to follow up on investigation results
- communication with other care providers at discharge
- signature of writer and role (e.g. level of training, consultant, most responsible physician)
Operative notes are often of great value in helping establish the circumstances surrounding an operative patient safety incident.
Operative notes generally include the following:
- the date on which the procedure took place
- pre-operative and post-operative diagnoses (if applicable)
- confirmation of completion of the pre-operative checklist, timeout and sign-out
- detailed outline of the procedure performed, including
- administration and timing of any medications such as antibiotics
- patient positioning
- efforts to identify and protect key structures
- intra-operative findings
- prostheses or drains left in at the close of the case
- complications, difficulties, or unexpected findings and surgical measures deployed to address these
- review of sponge and instrument count (i.e. a statement of its correctness at the conclusion of the case)
- patient status at the conclusion of the case (e.g. “stable and sent to recovery room” vs. “remained intubated and transferred to ICU”).
Discharge summaries are an important way to summarize a care episode and to communicate to others what the next steps are. Discharge summaries are often not available to others immediately after discharge. Consider whether a phone call or hand-written summary may benefit other providers who may need to be involved in care prior to the finalization of the official discharge summary.
Discharge summaries generally include the following:
- the course in hospital, including treatments and complications or ongoing problems
- who was consulted, consultant opinions, and actions taken in response
- investigations done, their results, and actions taken
- pending investigations to be done after discharge, including who is responsible for ordering and following them
- discharge instructions for the patient or family including follow up
- medication reconciliation (new, discontinued or modified medications including the most up-to-date dosing and frequency, with a clear plan for monitoring)
- follow-up plans
- discharge instructions (advice given to the patient or caregiver as to what symptoms and signs should alert them to seek further medical attention, and where and how urgently they should seek care)
- scheduled appointments
- handouts given and discussed with the patient or caregiver. Because they change over time, consider keeping a copy of the handout in the medical record.
- action taken to make relevant persons aware of the plans
When transferring care to another provider, clearly documenting the handover contributes to establishing and maintaining team situational awareness and enhances the safety of care. To facilitate team communication, clearly indicate who will be taking responsibility and when.
Documentation of handover plans and discussions may vary based on the situation. While your conversation with the next care provider is the key to the handover, consider including the following in handover documentation:
- the key history: specifically the background to the current situation
- your assessment of the current situation:
- working diagnosis
- key findings
- ongoing issues
- a list of action items including pending investigations, procedures, consultations or reports
- specific issues discussed or brought up by family or caregivers
The consent discussion should be documented in the patient’s medical record. The note need not be long and can be general yet specific enough to clearly refer to the conversation that took place to obtain the patient’s consent.
Consider including the following when documenting the consent discussion:
- discussion of risks
- specific special risks discussed in context of the patient’s individual situation
- any questions the patient asked and answers given
- the patient's apparent understanding (especially for a patient whose mental capacity or competency might be questioned)
- copies of any handout materials provided to the patient
- copies of signed consent forms
Is a signed consent form sufficient?
In many Canadian jurisdictions, it is now a legal requirement that a consent form be completed before any surgical procedure is undertaken in a hospital. The consent form itself is only an acknowledgement that the patient agreed to what was proposed. It does not speak to the quality or substance of the consent discussion. Follow hospital requirements, if applicable, for completing a consent form, but pay special attention to capturing the content of the discussion as opposed to simply completing the form. Remember:
- A consent form itself is not the patient’s consent.
- The dialogue with the patient is the key element of the consent process.
In witnessing a signature, the witness simply confirms the identity of the patient who signed the document. The witness's role has no other legal significance.
Advising patients to follow up “as required” or “if things don’t improve” may be overly general and may not help patients recognize specific signs and symptoms that signal an evolving complication or an alternative diagnosis.
When providing information at discharge, it is important that patients know they are welcome (made to feel comfortable) to return for re-evaluation. Document the advice you have given the patient when leaving your care. This advice includes:
- the clinical situation and the diagnosis (or differential diagnoses if there is uncertainty)
- specific symptoms and signs to watch for, alerting them to seek further medical care (i.e. that the condition is worsening or that the diagnosis may not be correct)
- where to seek care
- how urgently care should be sought
- information provided to the health providers who will be following up
- efforts to verbally contact the follow-up providers, if necessary
- copies of handouts used
- your assessment of the patient’s mental capacity, if appropriate (i.e. leaving AMA)
- the patient's reasons for refusing investigation or treatment (if leaving AMA)
- the patient’s refusal to take part in a discharge discussion or to sign an AMA form
When a patient safety incident (accident, in Québec) occurs or is discovered, document the facts in the progress notes, as follows:
- the facts as they are known (without speculation)
- the clinical situation as it now exists
- the consent discussions, options, and decisions made by the patient or family regarding any future clinical investigations and treatments
- any care provided
- any consultations and their rationale
After disclosure of a patient safety incident to the patient (or their substitute decision-maker), include the following details concerning the disclosure meeting in the progress notes:
- date, time, and location of the meeting
- name and roles of those present
- facts presented in the discussion
- participants' reactions and responses
- agreed-upon next steps
- any plan for providing follow-up and further information to the patient and family, if appropriate
- name and details of the patient's contact person
There are various ways physicians can help promote medication safety.
Reduce the risk of error by:
- using a leading zero before a decimal point for doses that are less than one (e.g. 0.2 mg instead of .2 mg)
- avoiding trailing zeroes after a decimal point (e.g. 5 mg instead of 5.0 mg)
- informing other healthcare providers of medication changes (e.g. patient’s family physician)
Document the following:
- patient evaluation
- rationale for choosing the specific medication
- consent discussion
- informed discharge advice
- the dosage and route of administration
- monitoring for any side effects regarding monitoring for adverse effects or medication efficacy
For opioid medications, consider using an opioid manager tool to simplify and streamline the documentation of care for patients using opioids. The documentation should include the following:
- your rationale for starting an opioid medication or changing the dose
- your consideration of the risks for addiction
- a well-defined treatment and follow up plan
- acknowledgement of the daily morphine equivalents being used/prescribed
- treatment agreements (like opioid contracts) for patients requiring chronic treatment
- any pain management consultations
A common cause of diagnostic delay is the failure to follow up with investigation or consultation results. Physicians who design follow-up systems that are able to identify patients with pending results, including those whose results have not yet returned, can minimize the chance of a patient not being followed-up. For that purpose, electronic medical record (EMR) systems typically allow automated reminders to be set for future dates.
It is good practice to document your policies for the follow-up of test results and notification of patients and others.
To promote safe follow-up of test results and leverage redundancies in the follow-up process, document the following:
- tests ordered
- results received
- reconciliation of the tests ordered and the results received
- time the results were received and reviewed
- action plan based on the results
- attempts to contact the patient
- follow-up appointments given
- any no-shows and the arranged appropriate follow-up of the patient, if necessary
If you received test results in error, document the steps taken to appropriately respond or redirect the test results (e.g. notifying the laboratory or diagnostic facility).
It is best to document events as soon as possible following the event (contemporaneously). Because memory about details tends to fade with time and may be blurred by other events, delayed documentation may lead to disputes concerning the sequence of events. For example, it may later be important to know if certain symptoms or findings were present before or only after a particular healthcare provider's intervention.
Documenting in real-time offers the additional benefit of promoting cognitive “slowing down.” The act of documenting can be used as a “cognitive forcing” strategy that allows providers to methodically work through their assessment, think through the differential, and plan for contingencies.
Documentation often serves as communication with other members of the team and this can be optimized when:
- a standard format is used (e.g. SOAP)
- only standard abbreviations are used (or none at all)
- notes are objective and relevant
- writing is legible (when using paper records)
SOAP stands for:
- Subjective (e.g. history)
- Objective (e.g. physical examination)
- Assessment of the patient's condition
- Plan for further investigation or treatment
Some medical regulatory authorities (Colleges) have specific guidelines about the format and timeliness of medical record keeping.
In the 1992 case of McInerney v. MacDonald, the Supreme Court of Canada made it clear that the information in the medical record belongs to the patient, but that the person or organization responsible for the creation, assembly and management of a paper record or EMR system is the custodian of the information. Privacy legislation has now reinforced patients’ common law right of access to personal information contained in their medical records.
Landmark Canadian legal case — McInerney v. MacDonald (1992)
When law and medicine intersect: patients' access to medical records
This Supreme Court of Canada decision established the principle that, although physicians own the physical medical record, patients have a general right of access to the information in their record.
That right of access, however, is not absolute. When the physician reasonably believes there is a significant likelihood of a substantial adverse effect on the patient's physical, mental, or emotional health, or harm to a third party, that information or part of the medical record does not need to be disclosed.
Why is this decision important?
Following the Court decision, privacy legislation established procedures for both seeking access to medical records and for responding to such requests. As well, administrative processes were implemented such that patient complaints concerning access are now resolved by a privacy commissioner rather than the judiciary.
Being the custodian of patients’ personal health information comes with statutory obligations established by privacy laws in each province/territory, which may include controlling access to the information as well as monitoring for and reporting breaches in privacy.
What this means
- Physicians should access information in a medical record only for clinical reasons and while they are a member of the patient’s circle of care.
- Patients have a right to access their personal health information in their record at any time and for any reason, subject to certain exceptions (e.g. if there is likelihood of harm to the patient).
- Electronic patient portals may enable patients to access their laboratory results before the ordering physician does so. To help manage patients’ expectations and potential anxiety when requesting tests, physicians may choose to discuss with patients the implications of such access.
- Patients can place conditions or restrictions on who has access to their information, even for providers within the circle of care. When patients ask for such restrictions, physicians should speak with them to determine whether there are concerns about their care or other underlying issues. Physicians should make reasonable efforts to accommodate these requests.
- All notations in the record must be professional and factual. Inappropriate notations can be embarrassing to, or even grounds for litigation against, the writer.
Electronic medical records (EMRs) facilitate easy access to, and management of, patients’ health information. EMR systems may also offer integrated decision support aids and alerts.
EMR-driven decision support aids and alerts
Decision support aids are tools embedded in EMR software that prompt the user to consider certain factors or possible decisions in response to the inputted data. The EMR may also include alerts, flags, or instant messaging capabilities to assist physicians in diagnosing, treating, and monitoring their patients’ clinical conditions or managing their prescriptions.
- Document your rationale for disregarding or for choosing an alternative to the suggestions provided by the EMR system.
- Make a note of your reasoning when acting on or disregarding an alert, flag, or instant message.
EMRs are susceptible to the potential for data loss owing to software or hardware failures, and malware.
- Ensure appropriate policies and procedures are in place to back up the data regularly, anti-virus protection is activated, and user passwords are changed regularly.
EMR systems contain an audit capability that records the date, time, and identity of each user viewing, adding or changing information.
- Annotate content changes with the time, date, and reason for the change.
- Refer to specific medical regulatory authority (College), hospital, clinic, or office rules about making changes or corrections to medical records.
While templates help to standardize how information is presented and save time for physicians, they may also decrease the personalization of notes and thus affect their perceived credibility.
- 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.
The custodian is responsible for controlling access to the EMR system and for reporting privacy breaches. Institutions routinely run audits of their EMR systems to help identify any unauthorized access.
- Access a patient’s medical record only for clinical purposes, while part of the patient’s circle of care.
- If you need access after leaving a patient’s circle of care, obtain authorization from the custodian of the record.
Informal interactions between colleagues form an important part of medical care. Nevertheless, information given or received informally often remains undocumented. Physicians who provide advice to either patients or colleagues may be found to have engaged their duty of care to this patient even if they have never met.
Similarly, informal discussions with colleagues (for example in a corridor or lounge) may affect a physician’s patient care decisions and may create a duty of care if the consulting physician knew or ought to have known that their advice would be relied on to make clinical decisions regarding the patient’s care. If there is an adverse outcome, the reason for those decisions may be questioned.
To promote clarity between colleagues, it is good practice to advise colleagues you consult informally whether you intend to use their advice to treat a patient. Similarly, if a colleague seeks your advice, it is wise to clarify whether you are discussing concepts generally or in the context of specific patient’s care.
- Consider employing a system for documenting who you spoke with, the date/time of the discussion, patient identity, and the information received and advice given.
There are times when a record may be incomplete or inaccurate. A patient may also request a change to their medical record. Corrections can be made, but must be done properly and clearly marked as a correction.
In general, physicians have a duty to correct inaccurate information.
- If you believe a record should be changed, the amendment should comply with the appropriate regulatory authority (College) requirements.
- If the change you make may affect the course of care, alert other healthcare professionals in the circle of care within a reasonable time so the patient’s treatment is not compromised.
If a patient requests a correction or amendment that you do not agree with, keep a copy of the request in the record as well as your letter of refusal setting out the reasons for refusing, along with any other communication.
If a patient requests that you correct or amend an entry made by another healthcare professional, direct the patient to make the request to that provider.
On a paper record:
- Cross out incorrect information with a single line, date and initial it. The original information should still be legible.
- Write the correction and the current date.
- If there have been subsequent notes, place the correction after the latest entry, date it, note the date of the notation being corrected, and include the reason for the correction (e.g. new information, patient corrected self, etc.).
Never make a correction or change an entry after learning of a complaint or legal action.
On an electronic record:
- Changes can usually be made using an addendum or digital strikeout
- Indicate the reason for the change.
- Enter the correct information.
- The date, time, and initials (or electronic signature) of the person making the alteration should be visible on the electronic record.
EMRs have an audit function that tracks who made any changes to entries and when. If the EMR allows deletions, typically the deleted text will be retained and remain accessible in the metadata. While deleted or modified information may not be visible to you on-screen, it will nevertheless be retrievable and traceable back to the person who made the change.
Never allow others to use your password and never use someone else's password when accessing an EMR.
- Contact the CMPA before making a correction or changing an entry after learning of a complaint or legal action.