Purpose of medical records
A medical record (patient record, case sheet, chart) is a written or digital account of everything done for a patient. We keep it because:
- Continuity of care: the next doctor or nurse knows what has been done and what to do next.
- Communication: the team (doctors, nurses, lab, pharmacy, therapists) shares one source of truth.
- Patient safety: allergies and medicines are visible, so errors are avoided.
- Legal proof: it shows what care was given; courts and inquiries use it.
- Billing and insurance: claims need records.
- Research, teaching and public health: anonymous data shows disease patterns.
- Quality checks (audit): hospitals review records to improve care.
Content of a medical record
- Identification: name, age, sex, address, contact, unique hospital number, next of kin.
- History: main complaint, present illness, past illness, family history, allergies, medicines, habits.
- Examination: vital signs (temperature, pulse, breathing rate, blood pressure, oxygen level), weight, findings.
- Investigations: blood tests, X-rays, scans and their reports.
- Diagnosis and treatment plan: medicines (name, dose, route, time), procedures, diet.
- Progress notes and nursing notes: daily changes, intake-output charts.
- Consent forms: signed agreement for operations and procedures.
- Discharge summary or referral letter; death certificate if needed.
Principles of good record keeping
- Accurate and factual: write what you saw and did, not guesses or opinions about the person.
- Complete: nothing important missing.
- Timely: write at the time or straight after, never days later.
- Legible and clear: readable handwriting, only standard short forms, no unclear abbreviations.
- Dated, timed and signed with your name and role. Use the 24-hour clock if your hospital does.
- Corrections: draw one line through the error so it can still be read, write the correct entry, then date and sign. Never use correction fluid or tear out pages.
- Confidential: share only with those who need to know for care, or with the patient’s consent, or when the law requires it.
- Patient-centred: patients usually have the right to see their own record.
Maintaining patient records
Paper records are kept in files, arranged by a unique number (numerical filing) or name (alphabetical). Colour codes and a register help find files quickly. A tracer card shows where a file went when it is taken out.
Electronic health records (EHR) keep the same data on computers. Benefits: easy to read, quick to search, can be shared between hospitals, alerts for allergies. Risks: hacking, power cuts and wrong data entry, so systems use passwords, role-based access, backups and an audit trail (log of who opened what).
Storage, retention and disposal
Records are stored in dry, safe, locked rooms or secure servers. Each country sets how long they must be kept (often several years for adults, longer for children and some legal cases). After that, paper is shredded or burnt and data is deleted securely.
Try it
Write a short “record” of your own day like a nurse: date, time, what you ate, your temperature if you have a thermometer, and sign it. Then check it against the ACT-LS rule.
Key formulas and definitions
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Worked examples
1. A nurse wrote “BP 160/90” but it was really 130/90. How should she correct it?
Draw a single line through “160/90” so it is still readable, write “130/90” beside it, add the date, time and her signature (and “error” if the hospital asks). She must not use correction fluid.
2. Write a SOAP note: a child says her throat hurts; temperature 38.5 °C; throat red; doctor thinks tonsillitis; gives paracetamol and fluids.
S: “My throat hurts.” O: temperature 38.5 °C, red throat. A: probable tonsillitis. P: paracetamol by weight, plenty of fluids, review in 2 days.
3. A hospital files 52,000 records and each folder is 2 cm thick. How many metres of shelf are needed?
52,000 × 2 cm = 104,000 cm = 1,040 m of shelf, one reason many hospitals move to electronic records.
4. A reporter phones asking about a famous patient’s illness. What should staff do?
Give no information. The reporter has no care role and no consent from the patient. Refer the call to the hospital’s official spokesperson.
Common mistakes
- Writing notes at the end of the shift from memory; details get lost or wrong.
- Using correction fluid or tearing out pages; this looks like hiding something and is not allowed.
- Writing opinions like “patient is difficult” instead of facts like “patient refused medicine at 10:00”.
- Talking about a patient’s record with friends or on social media; this breaks confidentiality.