Good Medical Record Keeping

Introduction: Good medical record keeping is at the forefront of medical practice. Not only do medical notes act as a learning tool, they are needed in medico-legal circumstances and more importantly, for patient safety and communication between multi-disciplinary team members. The General Medical Council wishes for clinicians to keep ‘good’ notes in a coherent, chronological and accurate order. Objective: The Royal College of Physicians (RCP) audit tool released in 2008 assesses 12 standards of medical notes, with which this audit has been conducted. The objective was to measure medical note keeping in accordance with published guidelines.

Method: A concurrent review of inpatient notes on a medical ward, Fairfield General Hospital (FGH) was undertaken with standards set at 100%. A questionnaire exploring attitudes to medical record keeping was also piloted.

Result: Standards measured increased over the 3 audit cycles with 3 of the indicators (writing a date, patient name and hospital number) reached 100%. The questionnaire showed 60% of the cohort had not read guidelines on note keeping and were dissatisfied with the standard of medical notes on their wards.

Conclusion: These results indicate medical note keeping has scope for improvement and auditing can improve standards. They also highlight a need for development in the way doctors are trained, with regards to medical note keeping

Author(s): Maiedha Raza

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