ABSTRACT
Health records should be clear, factual, consistent and accurate. It is the detail that is important as it tells us about what is going on with the patient. Health professionals go through the correct process and reach a professional judgment based on the clinical picture and other details, but then only record the outcome and fail to record the rationale for how they got to that point. Lack of clarity in the detail of the meaning of words compromises patient care. It exposes the health professionals – both the reader and the writer – to problems with legal and professional accountability. It is important that once a problem has been identified the detail of the action is clearly set out in the records. In addition it should identify who will follow through the action. If the health professional fails to record important information this can also lead to patient care being compromised.
