Patient health records: why they are important to your practice and reputation. This is the first in a series of articles regarding medical record keeping, by Dr Volker Hitzeroth, medico-legal consultant, and Dr Yash Naidoo, dento-legal consultant at Medical Protection.
It’s an ordinary Tuesday. Then an email lands in your inbox with a name you haven’t thought about in three or four years – a patient whose face you can’t quite call to mind. But today their name is on something: a letter from an attorney, a complaint lodged with the HPCSA, or a request from a colleague who has taken over their care and needs to know what you did, and why.
The moment that email arrives, something quietly changes. A file you wrote for yourself – with quick reminders, your own shorthand, notes meant only to jog your memory at the next visit – is now being read by someone else. This is the moment every clinical record is written for: not the consultation but the day someone else opens the file.
Most of us were never taught to write clinical notes with this day in mind. We were barely taught to write enough to treat the patient in front of us. That’s the gap this series of articles is about.
So, what is a health record?
The HPCSA’s definition (Booklet 9) is broad on purpose: a health record is the longitudinal collection of a person’s personal and health information, recorded by a practitioner – or at a practitioner’s direction – regardless of the form or medium used.
“Regardless of the form or medium” is the part people skate over. It does not say “the file in the cabinet” or “the entry in the practice software”. It says regardless. Hold that thought – we’ll come back to it, because it’s where most clinicians are exposed.
The booklet also frames records as a reminder, a tool for continuity of care, and evidence of the standard of care. All true. But there’s a simpler way to think about it. Your records are the version of you that stays in the room after you’ve left it; when you can’t be there to explain yourself. Years later, in front of people you’ll never meet, the notes speak on your behalf.
What a ‘good’ record looks like
A good record is clear, complete, concise, contemporaneous and consistent. It should reach actual conclusions, and someone should be able to pick it up, understand what happened and know what to do next.
In practice that means:
• A standardised structure, so anyone can navigate it: history, examination, investigations, diagnosis, treatment, outcome.
• The clinical reasoning, not just the clinical findings. The “why” is what most readers are hunting for, and it’s almost always the thing that’s missing.
• Made at the time, or as close to it as possible. Late entries are allowed – just label them honestly as late, date them, and add the reason for the late entry. Delete the erroneous text with a single line.
• No invented abbreviations. If a reader has to guess, you’ve lost the point of writing it down.
• No personal commentary.
The notes are not the practitioner – and that’s the problem.
Here’s something we see more often than we’d like: a poorly constructed file with records that are inadequate and hard to follow. Later, you meet that practitioner, and they are conscientious, careful and professional. The person and the paperwork don’t match.
Sometimes the person reading your file – the expert, the Council committee, the court – does eventually meet you. But they almost always meet your notes first. More often though, the file is the only version of you they’ll ever see.
The truth is that good clinicians leave poor records all the time. Your competence and your professionalism are real, but they are not in the room unless the record carries them there. The file is your stand-in, and it speaks first. If it sells you short, you’re on the back foot before you’ve said a word.
The line that sinks you
Let’s take an example of notes written by one of the authors of this article – and we’ll let you guess which one.
A patient presents late on a Monday morning complaining of a sore tooth. The clinician does a thorough, diligent examination and finds no abnormality at all. The patient accepts this readily (perhaps a little too readily) and then asks to be booked off work. And there it is: the clinician is now fairly certain this was never really about a tooth. It was about a long weekend with a sick note attached.
So, what goes in the file?
MC: Pain.
Exam: NAD.
Pt just wants sick note.
Look at that last line. It isn’t rude. There’s no insult in it – which is exactly why it’s such a useful example, because most of us would never write “difficult patient”, “exaggerating,” or “malingering” but almost all of us have written the quiet shorthand version of “patient just wants X.” It feels harmless. It isn’t.
The problem is that the clinician stopped recording the clinical picture and started recording a conclusion about the patient’s motive and then booked them off work anyway. So, to anyone who peruses the records later the note now reads: I didn’t believe this patient, I said so in writing, and I booked them off regardless.
The clinical examination was genuinely diligent, but you’d never know it from the file. The one line of editorialising has buried the one thing that actually defended the clinician.
The HPCSA says records should be free of self-serving, derogatory, discriminatory or emotional content. Anything you write to make yourself feel better in the moment, or to have a quiet dig is a sentence that might be read back – by the patient and possibly others.
Record what you found, what you did, and why you did it. The moment you start recording what you think about the patient, you’ve stopped writing a clinical record and started writing evidence against yourself.
Your phone is full of clinical records
Now back to “regardless of the form or medium”. Modern practice runs on informal channels, whether it be WhatsApp messages with patients, photographs taken on a practice phone, voice notes, or a quick email confirming a dose. And (increasingly) clinical images posted publicly: the before-and-after photographs that have become standard marketing in aesthetic, dental and surgical practice.
However, none of that is “informal” in the eyes of the HPCSA. If it relates to a patient’s care, it’s a clinical record, and it must meet the same standards as everything else. It must be recorded properly, stored securely, remain accessible, and be disclosable.
The before-and-after photo is the sharpest example. The image is not marketing that happens to be clinical.
It is a clinical record that you have also chosen to publish. The practical fix is simple in principle: anything informal must be transferred into the formal record, properly logged and stored.
The detail of how to manage that is a subject in its own right. For now, the guidance is: if it touches the patient’s care, it’s a record. The medium doesn’t get you out of it.
The record is rarely in one place
A patient’s “record” is almost never contained in a single file. The patient’s journey may run across a GP, an emergency unit, two or three specialists, a hospital admission, a separate radiology provider, a separate pathology lab, an anaesthetist, and perhaps a step-down facility. Each one holds a piece.
That’s normal, and it’s lawful – but it isn’t obvious to a patient who assumes you have everything. Knowing that this is how the system works lets you set expectations early and saves a fair amount of grief later.
The bottom line
Good record-keeping is itself one of the duties the HPCSA places on you. A practitioner can face a complaint of unprofessional conduct for poor records alone – independent of whether the actual care was sound.
Medico-legal matters also often surface years after the event, when no one reliably remembers the detail. On that day, the record is all there is, so write it for that day. Not because you expect it to come – most of the time it won’t – but because if it does, the file is either standing with you or standing against you.
Medical Protection members with concerns around patient records can contact us to request assistance.
See more from MedicalBrief archives:
Reducing medico-legal risk in WhatsApp and email use
Meticulous record keeping — a tedious but necessary task
Take note: Doctors want more guidance on record keeping
Court of Appeal swayed by surgeon’s detailed med scheme notes