It's time to take notes...

Good note-taking is critical so DHAA insurance provider, BMS, offer some tips on how to make sure your notes are thorough, reliable and easily accessible, should the need arise in the future.

QUICK QUESTION: What is the first thing you should do after you see a patient?

a) See your next patient; b) Complete your notes for the patient you just treated; c) Take a break.

If you’re not sure of the answer, then we recommend that you keep reading – it will definitely be clear by the end of the article.

Do you remember the specific details of the patient you saw on 8 November, 2017 at 3:30pm? Probably not, but what would happen if that patient made a complaint or claim against you weeks, or even months, after the alleged event? Perhaps you get a notification from AHPRA of an investigation into a patient you treated six months ago?

Taking notes is something you learn to do very early on in your development. It’s also a part of the job that’s easy to overlook, or become complacent with. What you may not know, is that keeping detailed notes could be the difference between being guilty or cleared of a claim brought against you. That’s right, your notes are more important than you might think. The more information that

you are able to supply during a claim or investigation – both through notes and other mediums – the better chance you stand of a positive outcome.

Here’s one example of how powerful a consistent, adequate set of notes can be:

A patient makes a complaint saying they were unhappy with the way you spoke to them. You’ve done nothing different and think nothing of it, you follow the note template and record all of your clinical work.

Later the patient makes a complaint about your conduct alleging you said inappropriate things, you look to your notes and have no record of the conversation.

Key Points to remember

1. Be consistent. Accurate note taking should be as important as your morning coffee. If you ever find your notes being taken into consideration during a legal proceeding, you will be judged, to some degree, on whether you consistently took accurate notes throughout your time practicing; and not just ad hoc or at the time of the alleged incident.

2. Be accurate and thorough. You don’t need to write a novel to be accurate and thorough, but you do need to include as much detail as possible, including anything unusual. Completing your notes immediately after seeing a patient is extremely important. Leave it too long and you will forget the details.

3. Never alter a patient’s record. This might seem obvious, but receiving a notification or claim can be stressful, and we all know that can sometimes cause a momentary lapse of judgment. Altering a patient record will never be tolerated.

For more information on your note taking or any other aspect of your current insurance cover, please contact BMS Group on 1800 940 762 or via email, dhaa@bmsgroup.com

WATCH OUR FREE WEBINAR

Clinical note taking The DHAA held a free webinar on clinical note taking and what your requirements are. It was presented by BMS and you can watch it here: https://dhaa.info/members/free-cpd-resources/