Medical records

Medical Records 1

Medical record keeping is an important part of any doctor’s professional work; it is even more vital out of hours. The patient contact made by a doctor working in OOH will often be the first and only time that patient is seen by that doctor. The medical record is therefore important to record the interaction in case of complaint and to facilitate continuity with the patients in-hours GP. There are a number of important issues that need to be recorded and it may be useful to use the template below to examine your record keeping.

Examine 20 consecutive medical records you have made, these may be face to face or telephone consultations or a mixture. Try to look at them as if your only contact with the patient is the medical record – ask “does this give me sufficient information?”

This tool can be used equally successfully by a GP working in hours as a locum or by a partner in a practice. Imagine the next doctor to see this patient only has your record to act on.

Please note this example is only a five stage audit, however it should be fairly simple to convert to an eight stage audit by repeating the data collection at an interval.

Medical Records Template

What do the findings tell you about your medical records?

Are there any learning points or actions from this exercise?

Medical Records Example

What do the findings tell you about your medical records?

This was an interesting experience for me, I tried to put myself in the position of not having seen the patient and to look to see if there was enough information for a doctor to glean sufficient information from the medical record to understand what went on in the consultation. I was surprised to notice at least 5 out of the twenty cases did not give a final outcome and that the diagnosis was not clear. The one area that I felt that I had not recorded information that I would have asked the patient was in the drug and past medical histories, I did not record negatives (ie no drugs or no PMH)

Are there any learning points or actions from this exercise?

Yes – I will try harder to record negatives and will include an outcome in each consultation even if that outcome is no diagnosis possible or no action taken. I will repeat this exercise next year to compare.


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