Patient Records and Documentation Requirements

The Patient Data Act contains provisions regarding the information that should be included in a patient record, provided that the information is available for documentation. Additionally, it outlines how the notes themselves should be written, ensuring they neither include too little nor too much information.

What information must be documented in a patient record?

Writing good journal entries is not entirely straightforward. The information should be concise yet not omit essential details. Simultaneously, all information should be easily readable and understandable by anyone accessing it.

The following information should be included in a patient record according to the basic regulations:

• Patient’s identity details
• Background of care or treatment
• Diagnosis and reason for further actions
• Completed and planned interventions
• Information shared with the patient, guardian, and other close relatives
• Treatment options and the possibility of new medical assessments
• Information on whether the patient chose to abstain from care or treatment
• Who made the entry and when it was made

Learn more about what should be documented by a healthcare provider here!

What should not be documented in a patient record?

The journal should not contain notes about third parties unless it is of utmost importance. Offensive or derogatory comments should also not be documented. Avoid including experiences that are not the patient’s own, such as the healthcare provider’s feelings about the patient’s condition or decisions.

Abbreviations and internal terms or concepts should be avoided to ensure the text is as easily readable as possible for everyone accessing the patient record.

Requirements for entries in the patient record

Every time a record is accessed to be read or updated, this should be logged, which happens automatically in an electronic record. It is also important to track who made a specific entry and when. Patients have the right to view all visits in their record, and the entries should be written in an understandable manner.

Entries in the patient record must not be deleted or made illegible. In cases where an incorrect entry has been made, it should be marked and corrected through a new entry. The entire history should be available for follow-up at a later date.

Entries that need to be documented in the patient record should be made as soon as possible. Additionally, the entry should be signed by the person responsible for the task, along with the date and time of the entry. Patient records are kept for at least ten years, and in some cases, indefinitely.

Tips for good journal entries

Patient records can contain a lot of information, but in general, the entries made should be concise and straightforward so that everyone reading can understand.

Here are a few guidelines for writing journal entries in the patient record that meet the requirements of a good entry:

• Write concisely without elaboration or narrative form
• Avoid personal judgments
• When personal interpretations are made, make it clear
• Spell out complete words instead of using abbreviations or slang
• Entries should only concern the specific patient, no one else
• In cases where professional contacts need to be mentioned, write out full names and job titles.

Systems that meet the requirements

MERIDIQ offers a user-friendly patient record system for healthcare providers to get started with and use. Patients can input relevant information themselves before their clinic visit, saving time for healthcare providers while ensuring accurate information is recorded.

The MERIDIQ patient record system can be used for free and is perfect for small newly established clinics looking to grow with their system. The system can be accessed from any device, both via the web browser and as an app, making it highly flexible.

Join over hundreds of satisfied clinics and try MERIDIQ for free!