Documentation, Health Informatics, and Record Keeping
Core concepts
Documentation is a legal record and a communication tool. Know the principles: accurate, contemporaneous, complete, legible, objective, and attributable (signed, dated, timed). Record assessments, interventions, patient responses, education, consent, refusals, and escalations. Use SOAP or profession-specific formats consistently.
Health informatics covers electronic health records (EHR), clinical decision support, computerised provider order entry, data security and confidentiality, access controls, and audit trails. Understand data protection obligations, minimum necessary access, and breach reporting. Know abbreviations to avoid and the risks of copy-forward documentation.
Traps in questions
- Late entries: acceptable if clearly marked as late with the actual time of entry; never backdate.
- Copy-paste: cloning prior notes can propagate errors and is a documentation risk.
- Objective vs. subjective: record what was observed and what the patient reported, labelled correctly.
- Access: curiosity is not a legitimate reason to open a record; access is audited.
Rule of thumb
"If it is not documented, it did not happen - and if it is wrong, correct it transparently." Never alter or delete an entry; add a dated correction.
Worked example
A clinician realises a note omitted a fall risk assessment. The correct action is to add a clearly labelled late entry with the current date and time, stating what was assessed and when - not to edit the original note silently.