Home › Record Keeping - No Standard Model and How Should Record Keeping and Documentation be Captured?

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NO STANDARD MODEL

Currently there is no standard model for record keeping. In 2004, Beverley Scott of the NHS Information Standards Board established that there is a lack of a standard model across the NHS for documenting and communicating information.

To achieve good medical practice, health professionals must keep up to date with legal requirements and record keeping; professional bodies should outline what they expect from their members; and organisations should have standardised procedures for recording and communicating information.

 

Scott B. Health record and communication practice standards for team-based care.
NHS Information Standards Board, 2004

Across healthcare there is a need for an efficient and transparent means of recording, transmitting and accessing reliable clinical information in order to deliver high-quality care to patients.
Chartered Society of Physiotherapists – Record Keeping Guidance 2016

 

HOW SHOULD RECORD KEEPING AND DOCUMENTATION BE CAPTURED BY INDIVIDUAL HEALTHCARE PROFESSIONALS?

KEY POINTS: 

  • Documentation in health-care records should be factual and mirror the care that is given
  • Written words can be misunderstood, particularly when documentation lacks numbers and units
  • Written words may be interpreted differently by the reader; saying that someone said something is entirely subjective—writing out what someone said in their personal record, however, is not
  • Vague and subjective words should be avoided wherever possible in a resident’s health-care records
  • Actions and omissions need to be written in a clear and objective manner in order to avoid ambiguity

 

Documentation should be a mirror image of what you have done/seen. If there is any question over clarity, check whether it states the FACTS—whether it is:

  • Factual (only record objective information)
  • Accurate (make sure that what is recorded is unambiguous, dated, timed and signed)
  • Consistent (ensure the record is consistent and reliable—you may need it at a later date)
  • Timely (record the information as it happens, whenever possible; leaving it for several hours, or even days later, will increase the risk of omitting key facts)
  • Shared (information needs to be communicated to ensure effective care and treatment; make sure it is

Smith and Parkhouse (2018)