Are your clinical notes up to scratch?
In this article, Dr. Andrew Arnold (Chiropractor) discusses why good clinical notes are important and some perspectives you may not have considered.
Good clinical notes are integral to professional clinical practice. All patient interactions should be well documented including with reception if this falls outside of regular patient-reception communication.[1]
Clinical notes not only serve as a valuable inter-professional communication but also in cases of auditing. The latter may relate to a legal matter or as part of your continuing education requirements.
Essentially, if it is not written or documented electronically at the time of the consultation, it not happen. This means you cannot go back to add information after the fact. Written notes where it is clearly evident they have been added to seriously discredits validity. Most practice management software platforms allow for a time period after the consultation to change or add to the notes without indicating a modification. Care must be taken not to intentionally or accidentally alter digital notes after the time out period.
Good clinical records are also important in the overall care of the patient. The seventh principle of the Caldicott report, an NHS report on patient information, says “the duty to share information can be as important as the duty to protect patient confidentiality”.[1]
Good clinical records can be a valuable resource in research, e.g. contributing to a case report. This may then allow for advances in treatment and diagnostic testing for future patients.
Good clinical records include consent and inter-consultation communications, e.g. phone calls, texting, emails, mail outs, etc.
In a multi-disciplinary environment, it is imperative every practitioner adheres to good clinical note practices irrespective of whether the patient has already presented to another practitioner within the practice.
Clinical note templates are a helpful way to ensure you tick all the boxes.
References:
1. Mathioudakis A, Rousalova I, Gagnat A, Saad N, Hardavella, G, How to keep good clinical records, Breathe (Sheff). 2016 Dec; 12(4): 369, 373. doi: 10.1183 / 20734735.018016
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Dr. Andrew Arnold is a Chiropractor and Naturopath, and ACTP accredited Business Coach and Founder: Million Dollar Wellness.