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30 August 2017
Clear, contemporaneous records are essential to support patient care. Dictated notes may pose problems if:
When treatment is being provided by a multi-disciplinary team, other health professionals must be able to rely on the accuracy of information recorded in the patient notes about medication and treatment.
If information about the previous clinical encounter is not readily available to the next treating clinician, it may adversely affect patient care.
The GMC advises that 'documents you make (including clinical records) to formally record your work must be clear, accurate and legible' and include relevant clinical findings; decisions made, actions agreed, and who is making decisions and agreeing the actions; the information given to patients; drugs prescribed or other investigation or treatment; who made the record and when.
If a problem arises later, it may be difficult to defend a doctor's actions if transcribed notes are incomplete or inaccurate, and the doctor is understandably unable to recall the consultation.
If possible, the doctor who dictated the notes should also transcribe them as soon as possible after the consultation has taken place.
When records have been transcribed by a third party, problems with the quality of recording or simple misunderstandings of medical terminology can lead to transcription errors.
For this reason, the doctor responsible for the patient's care should have the opportunity to check and sign entries before they are added to a patient's notes.
Doctors may also decide to include their GMC number alongside their signature, so there is no doubt as to who made the entry.
In addition, reports and letters should be seen, evaluated and initialled by the doctor concerned before being filed in the patient's records. Most test results are electronically transmitted, so care should be taken to record abnormal findings in the clinical records and document any appropriate action.
If hospital trusts are relying on clinical staff or external providers to transcribe dictated notes, it's important that the person or agency to whom this is delegated is trained and competent to carry out the task.
If you believe patient safety is being compromised by inaccurately transcribed records, you should draw the matter to the attention of your employer so it can be addressed, although it may be appropriate to discuss with your consultant first.
This guidance was correct at publication on 30/08/2017. It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.
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