What happens to the content of medical records?
Medical records have developed from brief, handwritten doctor’s notes to a wealth of documents authored by various types of health personnel, and they need to comply with a number of requirements (2). Although well aware of their legal nature, doctors regard medical records first and foremost as a tool for medical documentation and communication. Now, we increasingly need to relate to a third function: that of patient information.
We ought to ask ourselves what effects these various roles and the increasing and immediate availability of everything we write during a busy working day have on the words we choose, the content of the records and their quality.
Could it be possible that certain types of information are omitted? It might be important to document the therapist’s perceptions of the patient’s personality traits and degree of insight into his or her disease, especially where this may impact on the progress of the disease and the prognosis. Similarly, other potentially important information, such as suspicions of substance abuse, early dementia or a reminder to exclude cancer, might be omitted out of fear of invoking strong emotional reactions in the reader,
A further consequence could be that in their efforts to produce flawless patient record notes – and out of fear of reactions to what is written – health personnel refrain from communicating clinical reflection or doubt. This applies especially to patients who are under examination or suffer from conditions not yet determined, who often encounter specialty registrars for their initial assessment. A fear of writing anything that later might be construed as erroneous assessments might be a threat to entering good preliminary diagnoses, differential diagnosis discussions and clinical reflections in the records. It will be safer to focus exclusively on objective examinations and negative findings in convoluted record notes, often on the basis of a pre-defined template. Once these records have been signed, they will forever remain correct and unassailable.
So how should this uncertainty, the discussions with colleagues, the differential diagnosis discussions and the complicated prognostic thinking be recorded? On a slip of paper as «double-entry bookkeeping»? These are elements that ought to be documented in the hospital records, in the best interests of the patient.
Making a diagnosis has consequences. The patient may perceive it as stigmatising, but it may also trigger entitlements. Excessive caution in doctors when writing records may at worst cause a final diagnosis to be delayed. If we are increasingly reluctant to trust the clinical diagnosis, we are also apprehensive that the volume of unnecessary supplementary examinations will increase.
Traditionally, doctors have used medical histories and outpatient notes to provide positive or negative feedback to the referring doctor about medical and practical concerns that are not directly associated with the patient, for example constructive criticism of appropriate or less appropriate referrals. The outcome could be that we establish a number of information channels that bypass the patient records to provide clinical information between colleagues. There is little research on electronic access to records for patients, but some studies emphasise that the patients primarily regard it as positive. On the other hand, it has not been found that the quality of the content has improved or that this has brought health gains (3, 4).