Documentation

Abstract

The careful and accurate completion of medical records is not only an important physician responsibility, it is mandatory. Developing good habits of record keeping serves seven essential purposes:

• 1. Your record is an aide-memoir when you next see the patient.

• 2. A clear, accurate note is a guide for your colleagues who may need a quick review when seeing the patient in the years to come for continuity of care.

• 3. The clinic summary should be a concise summation of the many hours of thought, investigation, and consultation that were spent in attempting to unravel the patient’s problem.

• 4. Your notes are records of all diagnostic terms that are required for case retrieval in clinical investigations. References to the original pathology reports are essential in all tumor cases.

• 5. Flawless documentation affords a justification of payment by third parties, particularly when significant diagnostic efforts have been made.

• 6. All medical record notations must be timed in compliance with medical staff by-laws. Also, always clearly documents when an attending physician transfers patient care to another physician.

• 7. The medical record is a legal document and may be used in courts of law.

Anybody can make history. Only a great man can write it. —Oscar Wilde