[lettie]

I don't think it's wrong to tell the truth in medical records but the trick is to do it in a non-judgemental way. Social and psychological issues have a huge impact on physical health and such issues should be documented. Several years ago when I worked on community I had to visit a young lady with a rip roaring wound infection. The infection developed a few days after dishcharge from hospital and the wound was a sloughy smelly mess.

When I got to her house I couldn't help but notice the conditions in which she was living. The house was filthy, there were piles of unwashed dishes in the kitchen, the cooker and worktops were thick with grease and dirt. There was empty takeaway food containers with mouldy food in them all over the lounge. Old food and drink stains on the furniture and carpets, a mouldy dog turd on the hearth and the house smelled so bad that it was enough to turn even my stomach. Her husband sat all day in his vest at the computer and it was very obvious that neither of them made any effort to be clean. The body odour coming off them both was sickly and I did check that they had running water.

I cleaned the wound and organised some treatment and documented what I'd done in her notes. Later that day I went to the hospital and documented the exact state of the house and that I had advised them both about their personal hygiene. I also documented the treatment that I'd organised and that I would call back and visit again several days later.

About 3 months later my manager came to me with a solicitor's letter. The lass was trying to claim against the hospital for her wound infection, saying that it had developed in hospital and hadn't been treated. Due to my records in the medical notes the claim was kicked out....

We are not there to make personal judgements but sometimes the truth needs to be written, not only to cover us legally but to forewarn clinicians that there are social issues which may hamper recovery from treatment or may indeed be the cause of illness.