Best Practices: Protection with Good Clinical Records

The art and science of clinical record keeping deserves – but does not often get – as much attention as delivering quality healthcare. Yet proper record keeping – initial creation of the record, ongoing entries and maintenance, and retention – protects providers in a number of ways including:

  • Compliance Standards: Health care records are both clinical and legal documents. Failure to document patient care adequately can be considered evidence of negligence. For example, Oregon Administrative Rules Chapter 811-015-0005, Records, specifies, “It will be considered unprofessional conduct not to keep complete and accurate records on all patients.”
  • Malpractice Risk: Excellent clinical records are perhaps never appreciated so much as during a malpractice lawsuit. In the unfortunate event that a provider faces a suit, a well-documented and accurate patient file is a valuable asset. Even if a provider did everything right, as the saying goes, “If it didn’t get written down, it didn’t occur.”
  • Maintaining High Quality Care: No matter how good a provider’s memory is, keeping track of each patient’s unique clinical presentation, treatment plan, progress, precautions and outcomes is impossible without a record – either electronic or written – especially in a busy practice with diverse patient populations. Without such information, it’s also impossible to give good treatment advice.

How can providers make the record keeping process simpler and more straightforward? Here are a few tips to help providers and staff.

Adopt a System
There are many styles of chart notes to choose from that can be effective. Narrative notes in SOAP format are the standard. Whether in electronic or written form, there are a variety of ways to simplify clinical record keeping, including check-box formats, pre-printed forms, computer-generated notes, and barcode SOAP notes. However, some of these shortcuts produce “canned” notes that contain little clinical content. In whatever method chosen, be sure to leave room to completely document the clinical thought process for later reference.

Get Organized
If the office is using an Electronic Health Record (EHR) system, take the time to become very familiar with the standard functions so that it is easy to use during daily patient care. If the office is using paper charts and records, know where to look in every chart for the same data.

Check the Clinical News blog every Thursday through July for more in our Best Practices series