Writing poor medical records not only has negative implications in regards to legality and insurance, but they are a breach of proper duty of care. Ensuring that your patient is receiving the best treatment should be the absolute primary objective of delivering healthcare services, and this is heavily assisted by clinical documentation. To consolidate your understanding of what constitutes a good clinical note, we have collated some of the basic principles that should always be incorporated.
Firstly, it is important to provide an explanation of both the risks and the benefits associated with a treatment decision. For example, if a physician decides to medicate a patient, not only do they need to outline the associated risks, such as their aversive side effects, but they should describe the benefits of the medication and the risks of not taking the medication.
Secondly, you must include references to your clinical judgment. This may seem obvious, but as someone with both objective and subjective perceptions, all of your decisions need to be backed up by clinical reasoning. If it is determined you made a false decision, as long as your mistake was based on logical clinical reasoning, it is unlikely to be determined as negligent.
Lastly, your documentation needs to refer to the patient’s capacity to understand their own role in managing their care. This means you should record whether the patient understands any potential side effects of medication, the symptoms they may experience, what constitutes a medical emergency and whether they know who to contact in the case of said emergency. Including these three guiding principles into your medical records will guarantee they are concise, consistent, and serve as adequate protection against any possible lawsuit.