Notekeeping

All doctors should keep objective, factual records of their consultations with patients and of other professional work. Not only is this desirable per se, but also it is now a professional requirement. Current GMC guidance (23) states that in providing care doctors must keep clear, accurate, and contemporaneous patient records that record the relevant findings, decisions made, information given to the patient, and any drugs or other treatment provided.

Good notes assist in the care of the patient, especially when doctors work in teams or partnership and share the care of patients with colleagues. Notes then help to keep colleagues well informed. Good notes are invaluable for forensic purposes, when the doctor faces a complaint, a claim for compensation, or an allegation of serious professional misconduct or poor performance. The medical protection and defense organizations have long explained that an absence of notes may render indefensible that which may otherwise have been defensible. The existence of good notes is often the key factor in preparing and mounting a successful defense to allegations against a doctor or the institution in which he or she works.

Notes should record facts objectively and dispassionately; they must be devoid of pejorative comment, wit, invective, or defamatory comments. Patients and their advisers now have increasing rights of access to their records and rights to request corrections of inaccurate or inappropriate information.

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