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‘Documentation is an essential component of effective communication. Given the complexity of healthcare and the fluidity of clinical teams, healthcare records are one of the most important information sources available to clinicians.  Undocumented or poorly documented information relies on memory and is less likely to be communicated and retained. This can lead to loss of information, which can result in misdiagnosis and harm.’

Keeping records is often afforded low priority by practitioners when providing clinical care, despite being a clear professional obligation. The Code of Conduct for doctors in Australia, for example, sets out clear obligations in relation to medical records, stating that ‘maintaining clear and accurate medical records is essential for the continuing good care of patients.’

Good documentation is essential to robust clinical governance. This is reflected in the National Safety and Quality Health Service (NSQHS) Standards, which include actions around documentation (Action 1.16, ‘Clinical Governance Standard’ and Action 6.11, ‘Communicating for Safety Standard’). However, the importance of documentation stretches beyond accreditation, which sets the minimum bar. It is fundamental to good clinical practice and person-centred care, and hence in line with the professional obligations of health practitioners and their duty of care.

Safe, quality care cannot be provided without good records, therefore, clinical governance relies on this. Records enable continuity of care, preventing fragmentation.  They provide the information and context that is essential to sound clinical decision-making, hence mitigating the risk of error. Further, they are key to ‘setting the scene’ to ensure all care delivered is truly person-centred. Ultimately, records are the touchstone of good communication, which in turn is imperative to effective team functioning in a healthcare environment.

Keeping good records is a skill (as is effective communication), and a balancing act. Not only must records be clear and unambiguous, but complete and comprehensive without being so extensive that their quality or comprehensibility are compromised. Missing information can pose a risk of harm (such as the failure to record an allergy), or lead to unnecessary repetition of investigations, or ineffective treatment (through a failure to monitor and evaluate it), whereas, too much irrelevant information might confuse, confound or distract. At the same time, it is imperative to document negative findings (eg. ‘no pain’), rather than focussing only on positive findings (eg. ‘pain’), for it is equally important to communicate a lack of symptomatology, or absence of physical findings, as it is to identify their presence. 

Documentation must be objective and factual, and contemporaneous. Language should also be used with prudence and discretion. Not only must it be non-judgmental, but the choice of words and means of expression should avoid introducing any unconscious bias, for example, by communicating a negative attitude towards a patient.  Such biases and attitudes may have the potential to negatively impact the safety and quality of care subconsciously, for example through stereotyping, or by undermining person-centred care. It is also important to consider the range of people who might access the record (for example the patient, their family or lawyers), and how particular use of language might impact or influence them.

The same principles apply to electronic health records. Errors in electronic records are common and whilst some mistakes can be the same, such as an inaccurate description of symptoms, they also carry risks specific to their digital nature. For example, a lack of interoperability may mean greater gaps in information, and integrity of data might be compromised through the use of over-efficient practices, such as ‘copy and paste’, automated entries, or the use of ‘drop-down’ boxes; the haste of entry which they encourage can increase the risk of error.

Errors can also occur in interpreting an electronic record, perhaps due to the way software has been designed, inappropriate hardware, or user error. In a recent inquest, it was found that due to a failure to ‘scroll’ the information in an electronic medical record (eMR), a doctor erroneously read that a heparin dose had been charted, whereas it in fact been cancelled. The coroner found that ‘the monitor was not sufficiently wide enough to display all of the columns of information contained on the eMR’. The individual sadly died from a pulmonary embolus and had not received prophylactic anticoagulation despite his increased risk of venous thromboembolism.

In summary, health records are the golden chalice of clinical care. We must afford them the time and attention they deserve - keeping good records is integral to the role of health practitioners, not in addition to it. Further, records are a fundamental tool to be relied on in the course of clinical practice and support good clinical governance.

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All accessed on 20/22/22:

‘Documentation of information'. Australian Commission on Safety and Quality in Health Care. Accessed at: https://www.safetyandquality.gov.au/standards/nsqhs-standards/communicating-safety-standard/documentation-information

W. Abdelrahman and A. Abdelmageed. ‘Medical record keeping: clarity, accuracy, and timeliness are essential’. BMJ, 9 January 2014. DOI: 10.1136/bmj.f7716. Accessed at: Medical record keeping: clarity, accuracy, and timeliness are essential | The BMJ

B Madden. ‘Keeping records regarding informed consent: Unsatisfactory professional conduct.’ September 10, 2015. Accessed at: https://billmaddens.wordpress.com/2015/09/10/keeping-records-regarding-informed-consent-unsatisfactory-professional-conduct/

Gupta v Nursing and Midwifery Board of Australia (Occupational and Business Regulation) [2012] VCAT 1834. Accessed at: https://jade.io/article/684889?at.hl=Gupta+v+Nursing+and+Midwifery+Board+of+Australia+(Occupational+and+Business+Regulation)

‘Good medical practice: a code of conduct for doctors in Australia’. Medical Board, AHPRA. October 2020. Accessed at: Medical Board of Australia - Good medical practice: a code of conduct for doctors in Australia

Action 1.16. Australian Commission on Safety and Quality in Health Care. Accessed at: https://www.safetyandquality.gov.au/standards/nsqhs-standards/clinical-governance-standard/patient-safety-and-quality-systems/action-116

Action 6.11. Australian Commission on Safety and Quality in Health Care. Accessed on 20/2/22 at: https://www.safetyandquality.gov.au/standards/nsqhs-standards/communicating-safety-standard/documentation-information/action-611

J. Park et al. ‘Physician Use of Stigmatizing Language in Patient Medical Records’. JAMA Network Open, 14 July 2021. DOI: 10.1001/jamanetworkopen.2021.17052. Accessed at: Physician Use of Stigmatizing Language in Patient Medical Records | Electronic Health Records | JAMA Network Open | JAMA Network

S. K. Bell et al. ‘Frequency and Types of Patient-Reported Errors in Electronic Health Record Ambulatory Care Notes’. JAMA Network Open, 9 June 2020. DOI: 10.1001/jamanetworkopen.2020.5867. Accessed at: Frequency and Types of Patient-Reported Errors in Electronic Health Record Ambulatory Care Notes | Electronic Health Records | JAMA Network Open | JAMA Network

F. Schulte and E. Fry. ‘Death By 1,000 Clicks: Where Electronic Health Records Went Wrong’. KHN, 18 March 2019. Accessed at: Death By A Thousand Clicks: Where Electronic Health Records Went WrongKaiser Health News (khn.org)

M. L. Graber et al. ‘Electronic Health Record–Related Events in Medical Malpractice Claims’. Journal of Patient Safety, June 2019. DOI: 10.1097/PTS.0000000000000240. Accessed at: Electronic Health Record–Related Events in Medical Malpracti... : Journal of Patient Safety (lww.com)

‘Inquest into the death of Stephen Kline (NSW)’. State Coroner’s Court of NSW (file number 2016/82254), 1 March 2019. Accessed at: https://coroners.nsw.gov.au/coroners-court/download.html/documents/findings/2019/KLINE%20Stephen%20-%20Findings%20-%20Final.pdf