Clinical records and charting
Clinical records, charts, consultation and referral letters, forms and prescriptions communicate information needed for patient care. Their readers, specialised register and accuracy shape how that information is understood and acted on.
Purpose and readers
Clinical writing includes progress and treatment notes, chart updates, consultation and referral letters and administrative forms. It provides factual, accurate and specific information about patient conditions, diagnostic procedures, treatments and prognoses. Its intent is safe patient care through accurate, concise and factual documentation. It also has legal implications and can become evidence in malpractice or negligence lawsuits.
The primary readers are healthcare team members, including doctors, nurses, care aides, therapists, laboratory technicians and unit clerks. Health administrators, researchers and medico-legal professionals may also use the writing in some circumstances. Its tone needs to be recognisable and acceptable to these professional readers.
Register and terminology
Clinical writing uses medical terminology together with professional jargon: specialised words, abbreviations, acronyms and phrases. Charting is brief and cryptic and rarely uses complete sentences, whereas consultation reports and summaries mix formal and informal wording with more traditional grammar and syntax.
Examples of chart entries show both information and directions in terms familiar to peers:
- Failed to stamp clinical record with addressograph.
- Record apex numerically as appropriate. See flowsheet.
- Record O2 Sat numerically.
- Start IV to KVO. Maybe piggyback some antibiotics later. Vitals till then hourly.
- Wound has begun to ooze purulent discharge.
- Pt. crashed. Code called.
The chart entry “Resps. laboured. Placed in Semi-Fowler’s for relief. Puffer given” describes difficulty breathing, a semi-sitting position in bed to relieve it and two short inhalations of a bronchodilator through an aerosol device. Such compressed language is acceptable to healthcare professionals familiar with its style and vocabulary.
An excellent command of written English supports learning specialised vocabulary without having to learn basic English at the same time. Clinical writing has its own rules and structure. Unusual words and unfamiliar phrasing can obstruct communication because clinical readers are less receptive to language outside healthcare’s conventions. A consultation report overloaded with rarely used technical terms risks losing its importance and impact; appropriate medical terminology and professional jargon can communicate more effectively.
Specificity and patient safety
Specificity, accuracy, conciseness and professionalism each have safety consequences. Wordiness can obscure the message, and busy professionals rarely have time for long chart entries or consultation reports. Readers need the subject, priority of care and whether treatment, intervention or assistance has happened or remains pending. Verb choice and tense matter: wording that makes a pending treatment appear completed could result in its never being administered.
Two charting examples illustrate how language can mislead a clinical reader:
| Chart entry | Why it is an error | Correction |
|---|---|---|
| Patient calmed down after getting shot | This sounds as though the patient was shot with a gun and became calmer as a result. | Patient settled with an injection of anti-anxiety medication, XYZ 5 mg IM, right VG. |
| Pt presented in ER with complaint of stabbing pain in chest. No evidence of wound. Non-urgent. Waiting his turn in ER Waiting Room | The entry takes the complaint literally, missing “stabbing pain” as a diagnostic cue to myocardial infarction; the patient could possibly die in the waiting room. | Pt presented in ER with complaint of stabbing pain in chest. Urgent status. Admitted stat. Being seen now by physician. |
ER means emergency room, IM intramuscular, Pt patient and VG ventrogluteal muscle.
Prescription information and professional checks
A pharmacist’s courteous query can identify a prescription error: in one paediatrician’s early practice, a pharmacist queried a written dose of 5 mg against the usual recommended 1–2 mg. The physician regarded this courteous, cooperative interprofessional communication as exemplary and welcomed pharmacists’ scrutiny as a trained backup.
A 2012 proposal recommended putting the patient’s age, weight and diagnosis on every prescription to reduce errors; these were described as not ordinarily required by law and frequently omitted, especially diagnosis. Age can affect both dose and drug choice, particularly at either end of the age range; a two-year-old may need a different dose from a twelve-year-old. A fifty-pound patient may likewise need a different dose from a two-hundred-and-fifty-pound patient.
The proposal answered concerns about recording weight by treating the prescription as private communication between physician and pharmacist. It argued that the diagnosis was often already apparent from the medicine, giving vaginal creams, antiepileptic medicines, contraceptives, Rogaine and Preparation H as examples. When a pharmacist cannot decipher a drug name, the diagnosis can often identify it without guessing or telephoning the physician.
Habits can obstruct changes in prescription writing. In an account published in 2012, several physicians continued writing in cursive months after being told that Florida law required printed or typed prescriptions and receiving a copy of the law. The same account described recent pharmacy graduates’ clinical training, medical-pharmaceutical rotations in many schools and pharmacists accompanying teaching rounds at many major institutions to advise on medicines and doses. Recognising pharmacists as equivalent professionals and using their assistance can reduce prescribing errors.