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EDITORIAL

Medical Documentation- An Ignored Aspect in Patient Care
Ishtiaq Ahmed

Correspondence:
Prof Dr. Ishtiaq Ahmed
Consultant & HOD, Surgery
Al-Nafees Medical College & Hospital, Islamabad
E-mail: surgish2000@yahoo.com

Received: Feb 19, 2018; Accepted: Feb 22, 2018

The medical record is the wellspring of data for 
countless decisions regarding patient care from 
doctors, paramedical and administrative staff. Even 
though, during recent years the ancillary activities 
like audit, research, legal etc which depend on the 
medical record have received most of the attention. 
The most frequent problem encountered by 
administrative and medical authorities is probably as 
old as the concept of the medical records itself i.e. its 
completion in time and in accurate manner. An 
inaccurate or incomplete medical record reflects that 
the patient care was incomplete. Medical record 
which contains gaps depicts poor clinical care, 
demonstrate non-compliance with institutional 
policies and can be used to support allegations of 
negligence or fraud. Moreover, an incomplete 
patients clinical documentation can leads to legal 
actions, can results in loosing job, contribute to 
imprecise quality and care information, leading to  
lost revenue/reimbursement to institution or 
physician,  inappropriate billing and leading to 
charges of fraud. In addition, incomplete or improper 
documentation interfere with research, data analysis, 
patient-related studies and most likely compromises 

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safe patient care.  That's why every health care 
provider institution should ensure timely, precise and 
complete clinical documentation of all patients at any 
cost.
Keeping in view all this, the proper documentation 
has become an integral part of patient management 
and it has evolved into a science of itself. This is the  
only mode for clinician to prove that a proper 
treatment was carried out. There is a strong 
consensus that properly maintained medical record 
is of immense help in the scientific evaluation and 
analysis in patient management issues. Its 
s i g n i f i c a n c e  f o r  c l i n i c i a n s  a n d  m e d i c a l  
establishments is for three important reasons. 
Firstly, it will help them in the scientific evaluation of 

patient's profile, treatment outcome analysis, and in 
planning the treatment protocols. Secondly, it is also 
helpful in planning institutional or governmental 
strategies for future medical care. In addition, it is 
also used to inquire the issue of alleged medical 
negligence during treatment because the legal 
system relies mainly on documentary evidence. In 
these scenarios, the documentation is the most 
important evidence which decide the sentencing or 

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acquittal of the doctor.  
It is disheartening to observe that in spite of knowing 
the significance of proper medical record keeping, 
this matter is still in a nascent phase in our country. It 
is wise to remember that “Poor records mean poor 

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defense, no records mean no defense”.  Abernethy 
et al after reviewing the documents has observed 
that insufficient data availability has hindered the 
quality assessment. Of the all eligible patients for 
analysis, only 12.22% patients can be included in the 
full analysis. They observed that the sex was un 
identified in 17%, missing data on race or ethnicity in 
26%, confirmed diagnosis in 86%, only 38% provided 
TNM stage, missing histo-pathology in 34% and up to 
10% of records did not revealed dates of 
administration of chemotherapy to the patients. 
After switching to electronic medical record keeping 
the reporting has improved significantly but 
documentation problems persisted. Overall, they 
concluded that the records containing data sufficient 
to evaluate conformance to the colorectal cancer 

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metrics, conformance was low as 50% to 70%.  
Medical records comprises of a variety of 
information's from patient's history, clinical findings, 
investigations, treatment planned, pre and post-
operative care, operation notes, daily progress notes 
of a patient, diagnosis, discharge summary and 
follow up plan etc which can be used for varied 
evaluations. For example, in case of a surgery, a 
properly obtained consent will go a long way in 
proving that the surgical procedures were carried 
out with the patient's concurrence. Similarly, 
meticulous or properly endorsed operation notes 
can protect a surgeon in case of alleged negligence 
claims. It needs to be the concerted effort of all 

Department of Surgery
Al- Nafees Medical College & Hospital, Islamabad



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JIIMC 2018 Vol. 13, No.1  

members of team who are involved in patient care in 
keeping the proper medical record. In this regard, the 
doctor is the prime person to oversee this 
documentation process and is primarily responsible 
for patient's histor y, clinical examination, 
investigation plan, treatment prescribed, operation 
details, consent forms, referral notes, discharge 
summary and medical certificates. Other than this, 
proper recording of nursing care, laboratory data, 
diagnostic evaluations reports, record of pharmacy 
and billing processes is also crucial which needs to be 
maintained by paramedical or administrative staff. In 
order to maintain proper hospital record, doctor, 
paramedical and nursing staff should be trained 

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properly.  
The medical facilities in Pakistan range from smaller 
clinics to large hospitals and from private sector to 
public sector medical facilities. Proper medical 
record keeping is a separate and specialized domain 
in some of the public sector, teaching and corporate 
hospitals of urban setup which are having dedicated 
medical records officers capable of handling these 
documents. However, it is yet to develop into a 
proper record keeping process in majority of 

hospitals and clinics that provide medical facilities to 
a large section of the people in Pakistan. To conclude, 
when documentation is complete and accurate in all 
domains, it works wonders at telling a patient's story 
and can even improve patient care. To achieve this, 
the documentation in the medical record needs to be 
complete and accurate to facilitate effective 
continuum of care.”

REFERENCES
1. Po o r  d o c u m e n t a t i o n :  T h e  c o n s e q u e n c e s .  S t a f f  

Development Weekly: Insight on Evidence-Based Practice 
i n  E d u c a t i o n ,  J a n u a r y  3 1 ,  2 0 0 8 .  W e b s i t e :  [  
www.hcprofessor.com].

2. Schaeffer J.  Poor Documentation: Why It Happens and How 
to Fix It. For The Record . 2016; 28: 12-6.

3. Thomas J. Medical records and issues in negligence.  Indian 
J Urol. 2009; 25: 384–8.

4. Griffiths P, Debbage S, Smith A. A comprehensive audit of 
nursing record keeping practice. Br J Nurs. 2007; 16: 1324-
27.

5. Prideaux A. Issues in nursing documentation and record-
keeping practice. Br J Nurs. 2011; 20: 1450-4.

6. Abernethy AP, Herndon JE,  Wheeler JL,  Rowe K,  Marcello 
J, Patwardhan M. Poor Documentation Prevents Adequate 
Assessment of Quality Metrics in Colorectal Cancer. J 
Oncology Practice. 2017; 12: 234-9.


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