Doctors say they need help with paperwork

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Respondents were from a variety of clinical backgrounds, including consultants and general practitioners in both public and private practice. Almost all survey respondents (94%) agreed that accurate record keeping was part of their professional responsibility. Despite acknowledging the importance of good record keeping, the survey found just under 12% of doctors had undertaken specific training in keeping medical records.

Most doctors also indicated they would like more guidance on good record keeping.

The vast majority of doctors feel they keep good records and half the survey respondents reported that they had been complimented on the quality of their record keeping. However, challenges remain as 8% have had a colleague complain about their record keeping and 14% have had a patient complaint, claim or local issue where record keeping was identified as a component.

When asked about the challenges of record keeping, prominent barriers included that the process was time consuming and that doctors had a high workload. Other barriers included habit, insufficient computer skills and lack of training.

“Doctors understand the importance of good record keeping, both for themselves and for the welfare of their patients. Good clinical records are a prerequisite to delivering high quality care and ensuring continuity when a number of different clinicians are contributing simultaneously to patient care.

“The constant drive to improve the quality and safety of medical practice, and the increasing expectations and costs of medical care, means the structure and content of the clinical record is becoming ever more important.

“Poor record keeping can contribute to an adverse outcome such as a delayed diagnosis and could lead to a complaint, claim or a referral to the Health Professions Council of South Africa (HPCSA).

“Maintaining complete contemporaneous records enables a doctor to provide evidence of the care given and thus is invaluable if they have a complaint or claim of clinical negligence," Graham Howarth, head of medical services, Africa for MPS.