ABSTRACT
Health records are written for the purpose of treating, supporting and caring for the patient. They are the tool of communication between professionals, patients and carers. However, it has been identified that too often notes seem to be written with medico-legal rather than communication purposes in mind. Defensive record keeping can easily become poor record keeping. Health professionals should not be tempted to write the records defensively or to write the notes with litigation in mind. There is a danger that the records will become stylised, verbose or convey different messages from those intended. Remember, the purpose of the records is to facilitate the care, treatment and support of the patient. If they are written defensively there is a danger we move away from their real purpose. This may then result in a breakdown in communication.
