Good quality medical records are essential to the proper ongoing care of patients and the defense of any claims made against doctors.
What is a medical record?
A ‘medical record’ is a general term for all of the information collated about a patient for the purpose of treating that patient, including:
- Progress notes – handwritten or computerised
- Specialists’ letters and other correspondence
- Test results
- X-rays and scans
- Digital recordings
- Appointment books and patient accounts
- Medical records should include the following information:
- Patient identification
- Information relevant to diagnosis or treatment
- Treatment plan
- Medication and dosage levels
- Information and advice given, consent discussions
- Details of any medical or surgical procedure (date, nature, who performed procedure, type of anesthetic, tissues sent to pathology, results or findings, written consent)
Medical records should also comply with any relevant legislation for record keeping.