Patient record keeping functions as a legal document addressing all that was completed during the medical consultation process by the practitioner. That being said, embedded in such a document are legal, ethical, and professional requirements which must be met. A patient record must be clearly written using the commonly accepted symbols, abbreviations, and appropriate measurements as dictated by the Society of Chiropodists and Podiatrists. It is only through good record keeping that good communication can be maintained between professionals treating the same patient, and between the patient and the professionals from whom they are receiving treatment. And yet, there exist common issues that arise with regard to maintaining accurate and confidential patient records.
One of the most common problems is a lack of clarity among the written notes. For example, a doctor might notate that the patient “slept well” or “had a good day” neither of which afford any clarity to anyone else reading the notes. Another common problem is the failure to record which actions were taken after a problem was identified. A patient record might state that the patient was suffering from increasing pain, but there are no follow up entries to explain what action was taken to mitigate the increasing pain felt by the patient. In some cases there is information missing, such as a missing annotation for the administration of a particular drug. This can be particularly problematic when that drug was previously recorded in its administration but one or two administrations were not recorded. This raises issue of whether the patient received the full dose of their prescribed medication or not.
When filling out patient records, spelling mistakes may seem inconsequential but can be tantamount to naming the results of an incorrect diagnosis. Inaccuracy of records is another common issue. Records might state that a patient was given medication or had their dressing changed when this is in fact entirely untrue, which can result in a nurse being removed from the register. In some cases, conversations might take place among medical physicians or with the patient in informal settings and they go without documentation. It is far too easy to attempt to fill out a conversation right after it happened, only to be inundated by other work requests to the point that the documentation of said conversation is lost. Still other common errors include a failure to document which care was administered to a patient, or whether there are any special needs of the patient. Telephone calls made in relation to the patient, such as a call regarding the risk of suicide, can sometimes go undocumented.
Posing serious problems with the maintenance of confidential patient records, these problems can be mitigated by using the SOAPE system. The SOAPE system functions as an accurate and reliable recording method that ensures completeness and accuracy. The method consists of the five letters written in a perpendicular fashion with the information for each section immediately following along the same horizontal access.
“S = symptoms described by the patient
O = objective signs observed by the practitioner
A = action taken that day
P = plan of management for patient as agreed between the two
E = evaluation of previous treatment given, and thus a synopsis of how the management plan is progressing” (Frowen et al., 2010, p. 15).
- Frowen, P., O’Donnell, M., Burrow, J. G., & Lorimer, D. L. (Eds.). (2010).Neale’s Disorders of
the Foot. Elsevier Health Sciences.