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The Importance of Recording Instructions, Treatments and Observations

December 1, 2016 1 Comment

There is a saying in the health care industry: “If it’s not written down, it didn’t happen”. This only begins to sum up the importance of recording instructions, treatments and observation.

In the medical setting, health records are a thorough documentation of everything that a patient undergoes throughout a treatment process, so it is vital for healthcare workers to commit to these records.

A medical record documents all the treatments being carried out by the attending physician, observations, and instructions on medicines and after care management that nurses and other health care workers need to provide to a client/patient. These records need to be properly maintained for two valuable reasons:

  1. This will be the basis of the evaluation of the patient profile to analyse treatment results that can help in creating sound strategies for future medical care.
  2. To avoid medical negligence and medical malpractice.

Any healthcare provider who is found guilty of medical negligence or malpractice may face serious penalties that may result to suspension or nullity of professional licenses – and in some extreme cases, prison. Whether the negligence was intentional or not, if the patient’s health is compromised due to the wrong information being recorded on the client’s records, the person who committed the mistake will be reprimanded.

To help avoid medical negligence, healthcare workers need to provide accurate, comprehensive, and concise client records.

Here are a few important practices to adopt for effective record keeping:

  • Ensure that the client’s health record begins with an identification sheet that contains the patient/resident’s full name, age, address, attending physician, and person attending to them.
  • Create an efficient systematic approach that is easy to follow. Make sure that everyone in the team (doctors, nurses, caregivers) understand and know how to use a standardised form (whether digital or paper) for record keeping. This will ensure clear and consistent documentation of all the treatments and management given to the patients.
  • Always provide a timestamp and signature in every entry written in the document.
  • Write in clear handwriting and use dark ink so that it can be easily seen.
  • Remember to record all medication given to the patient throughout the day and never leave a station without signing a prescription sheet.
  • Record all relevant observations including changes in blood pressure and heart rate. Also take note of the patient’s complaints or treatment progress.
  • Always provide a written record for every endorsement or instruction given by an attending physician. This reduces the possibility of misunderstandings when you are not available.
  • When in doubt, consult your colleagues before carrying out an ordered procedure.

These little things can easily become a habit when practiced regularly. And by taking these practices to heart, you can ensure that your clients’ medical records reflect quality of care and standard work ethics.

Filed in: Workplace Tips

About the Author:

Olive resides full time in the Training Centre of Back to Basics Care. She assists students to perform activities that take place within a health care setting. Her role here on the website is to keep you up-to-date with research and study outcomes within the health care sector.

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