Is the statement ''Good record-keeping shows good clinical care'' true Discuss - Assignment Example

A good clinical record should include: (1) pertinent information of the patients’ medical history, including important negatives; (2) examination results, including important negatives; (3) differential diagnosis; (4) details of any laboratory exams ordered, and any treatment provided; (5) patients’ progress report; (6) follow-up schedules; (7) information shared with or discussed to the patient, such as associated complications of a treatment; and (8) patients’ non-compliance of the treatment (Medical Protection Society [MPS], 2011).

This should be written objectively, clearly and legibly; with the name and signature of the medical practitioner; as well as the date and time of examination affixed after the report (MPS, 2011). Clinical records are part and parcel of patient care, which ensures the safe delivery of health care, as well as positive patient outcomes. Medical records are the basis for establishing a high quality of patient care (Ram & Carpenter, 2007). It is a vital tool that allow medical practitioners to understand; learn from; and correct errors made in the past (Ram & Carpenter, 2007). . A detailed account of patient complaints help medical practitioners focus treatment plan and care provision on the problem presented; and on its associated complication.

It provides a list of objective manifestation that form the basis for the diagnosis; and it prevents deviation from the ideal course of treatment. By setting out on a treatment course designed for the patient, unnecessary tests, medications, procedures, as well as expenses can be dodged; and a focused plan of care can be applied. According to Blake (2010), “good record-keeping will assist the member in accurately recalling the starting point with the client, the agreed-upon goals and process, and evaluating the extent to which the goals have been achieved” (p.15). Information contained in medical records serve as a basement data with which present, and future assessment findings can be compared with.

This aids the health providers in deciding; in planning; and in evaluating the treatment regimen and other interventions for the patient. Documenting assessment findings, outcome interventions, and other observed manifestations, can help medical practitioners monitor the progress of patient care; and identify, as well as prevent possible adverse effects resulting from the treatments employed. In a study by Pomeranz (n.d) on deaths caused by medication errors, he emphasized that “.better awareness can help prevent some of the deaths [caused by adverse medication reactions;].

and better record keeping can help prevent patients’ being given drugs that they have had allergic reactions to in the past.” (as cited in Grady, 1998, n. pag.). Pertinent information that can affect