This document discusses the importance and standards of clinical documentation. It notes that documentation is important for planning treatment, communication between providers, and providing a single source of truth. Good documentation promotes patient safety, cuts down on duplicative work, and provides a record in case of audits or malpractice claims. The document outlines standards like including patient ID, dates, medical history, allergies and notes the legal aspects of documentation like avoiding erasures, being accurate, and maintaining confidentiality. It discusses the benefits of electronic records for storage and access while noting some financial costs. The purpose of documentation is for planning, organization, coordination and control of health services.

1. By
Dr . Shaymaa Kotb
Master degree from Alazhar university
M RCSI , RCSEng , RCSEd ,RCPSG
DOCUMENTATION OF THE CASES

2. OUTLINES
PURPOSE OF RECORDING
IMPORTANCE OF DOCUMENTATION
DOCUMENTATION IS EVIDENCE
 STANDARD OF DOCUMENTATION
LEGAL ASPECTS
ELECTRONIC RECORDING
CONFEDENTIALITY

3. PURPOSE OF RECORDING
Planning
Organization
Co-ordination
Control of Health services

4. IMPORTANCE OF DOCUMENTATION
 Good documentation is central to good clinical
practice
 Key for documentation : must keep clear,
accurate and legible records
A single source of truth , saves time and energy
Documentation cuts down duplicative work

5. DOCUMENTATION IS MY BEST FRIEND

6. IMPORTANCE OF CLINICAL DOCUMENTATION
protect your patients.
 Good documentation promotes patient safety
Vital means of communication between dr and pt
 Empower the healthcare providers to plan the
treatment, thus improving the overall quality of
healthcare services.
Clinical records also provide data for use in audit
and research

7. DOCUMENTATION = EVIDENCE

8. DOCUMENTATION = EVIDENCE

9. STANDARDS OF DOCUMENTATION
Must have the patient’s ID number
should be dated and timed with the 24-hour clock.
Name of patients’ data , it must include:
Date of birth
The contact number,
Employer, address,
Marital status.

10. STANDARDS OF DOCUMENTATION
The medical conditions or illnesses of the patients.
On top of everything, the potential adverse
reactions
 Medication allergies must be outlined.
The past medical history
Somking state
Alcohol state

11. IDENTIFICATION OF STANDARD OF
DOCUMENTATION
Education & Awareness
Reviewing the Information
Declaration of Legal Health Records
Authentication, Dating, And Timing (in a written
form)

12. LEGAL ASPECTS
Misinterpretation
Medical Errors
Malpractice Claims in Medicine
Unauthorized Access

13. LEGAL ASPECTS
Don’t erase or use white –out
Don’t write critical comments ( don’t blame on your
colleagues)
Correct all errors promptly
Spell correctly
Record all facts
Be accurate about time
Avoid vague statement

14. ELECTRONIC RECORDS
use of electronic records overcome many problem.
Doctors have a duty to write legibly.
The ability to find information at any times
 Storage problems associated with the current
paper-based clinical notes
Financial Issues(cost)
Provide clear guidance for medical students

15. CONFDENTIALITY = DON’T DISCUSS WITHOUT PURPOSE

16. “COURT BELIEVES YOUR DOCUMENTS ONLY”

17. CONFIDENTIALITY = SECRETS

18. REFERENCES
 .General Medical Council. Good Medical Practice.
London: GMC; 2013.
The Royal College of Surgeons of England.
Guidelines for Clinicians on Medical Records and
Notes. London: RCS; 1994.
The Royal College of Physicians. Generic Medical
Record Keeping Standards. London: RCP; 2009.

20. THANK YOU
•
By
• Dr. shaymaa kotb