Poor record-keeping a time-bomb for medical practitioners
Meticulous record keeping by medical practitioners should be a key component of any healthcare system. File
What you need to know:
The rise in medical malpractice suits means that emphasis is being placed on individualised patient record keeping.
An evaluation of most small practices, nursing homes and public hospitals suggests that of the existing facilities, up to 80 per cent would benefit from stationery.
Medical records management has always featured as the weakest link, especially in regards to medical malpractice suits. In a few such cases highlighted in the media last week, proper documentation would have averted some suits or saved innocent health workers.
Thorough and meticulous details are key components of a good healthcare records system. Despite its importance, record keeping is still below par for both public and most lower tier private sector operators.
One glaring shortcoming of the current record keeping system is that it is not tailor-made for local practitioners.
In one of the cases highlighted last week, medication was alleged to have been given to a patient though not prescribed. Involved parties in such disputes are often not able to agree or remember where verbal orders are given. Best practice is to have everything documented and action, particularly for potentially life-changing decisions, not to be taken unless a written order is present.
For most clinics, however, availability of quality medical stationery is a nightmare. For small enterprises, cost-cutting measures dictate that branding and similar associated services be kept at a minimum. As such, many opt to buy readymade stationery in bulk.
The rise in medical malpractice suits means that emphasis is being placed on individualised patient record keeping. The Medical Practitioners and Dentists Board sometimes has to hear suits brought years after incidents occurred.
Anyone who has visited a government hospital has noticed that patients take home green or blue exercise books that act as their medical records, a risky legal scenario. Such records are not in the custody of the hospital as they ideally should.
While this is aimed at making it easy for a patient’s records to be accessed by alternative practitioners, from a legal point of view this is a loaded gun. In cases where such records are needed and the hospitals do not have them, it would be the first culpable offence – poor record keeping.
Public health facilities may have previously relied on their “government” status to shield them from such suits. However, recent judgments have also gone against public hospital practitioners. This should make those working there to recommend better record keeping and internal storage.
While automation is guaranteed to ensure accuracy of the digital records kept, it is inevitable that manual records will still remain with us.
An evaluation of most small practices, nursing homes and public hospitals suggests that of the existing facilities, up to 80 per cent would benefit from stationery. This suggests there is a viable market for such products.
The medical associations and insurance companies have a mandate to promote, both through education and guidance, better record keeping among their members. As a beginning engagement with the local stationery industry, guidelines and standardising of such records in the sector would be a good start.
The producers should also talk to medics on how such stationery can be adopted countrywide.
