Guidance on good record keeping in the NHS
Hi, my name is Anshika. I am an IMG from India. I work as an SHO in Trauma & Orthopaedics. This is my first job in the NHS, and I have been working in this post since August 2022. Through this blog, I will discuss the importance of good documentation in the NHS and how to make sure you are always on top of your documentation.
Why focus on this topic?
GMC Good Medical Practice (2013) states that doctors should record their work clearly, accurately, and legibly. Records are important for safe patient care, and it is the health practitioner’s responsibility that records are maintained to ensure that patient care is not compromised. Documentation forms an essential means of communication between different members of the team that look after a patient in the NHS, for example, doctors, nurses, physiotherapists, occupational therapists, and so on.
Good communication between multidisciplinary teams ensures the continuity of patient care. Documentation is important for medico-legal reasons too. As the indemnity providers like to say - no document, no defence, which essentially means that if you have not recorded your own version of events, you will not be able to defend yourself in a court of law. MDU (indemnity provider) states that - Records can be used as evidence in the event of a complaint or claim.
What do I need to remember to ensure good record keeping?
Remembering the following points will help:
1. Your records should be clear, accurate, and legible (Many NHS trusts are electronic now; however, there are some trusts that use paper notes still, so make sure to record legibly where you are required to. Also, you are required to only use black ink for paper notes in the NHS).
2. Ensure that you make records at the same time as the event or soon after (if that is not possible, enter your record as a retrospective entry).
3. Don’t forget to document difficult conversations with the patient or their families (for example, conversations around DNACPR, bad news, end-of-life care, the duty of candour conversations, etc.).
4. Make sure you are documenting for the intended patient (check their details before putting in a note).
5. Confidentiality is very important. Always dispose of patient identifiable information in the confidential bin and do not leave it lying around for others to discover and report.
6. Avoid ambiguous abbreviations.
7. If an addendum is being added to the notes, it should be signed and timed (you can add prospective addendums, but do not retrospectively addend notes. If there has been a factual error, run a single line through it so that it is still legible and correct it with your signature and time).
What should your note include?
Your records should include the following:
1. Relevant clinical findings
2. Likely differential diagnosis
3. Action plan and who decided and agreed upon the plan
4. Information given to the patient
5. Patient’s concerns and wishes
6. Any drugs added or drug chart modified in any way
7. Any investigations requested or any investigations that need chasing
8. Details of the person making the record and when, along with their GMC number
Does every event need to be documented?
Daily ward rounds are essential to be documented because they provide an action plan for the ward staff to follow. Apart from that, you should record all patient interactions relevant to their treatment. You should also record any discussion with clinical colleagues or third parties like the patient’s GP practice or their care homes.
Need more help?
If you have any further questions about working in the NHS, I would be happy to answer them at trewlink.com. You can register using this link. Find me as an Ambassador/Expert and follow my profile – Anshika Tyagi - to receive regular support and advice.