Conquering Record-Keeping for Healthcare Professionals

23-11-2015

Author: Joanelle O’Cleirigh, Orla Keane and Roberta Guiry



While it may not be a healthcare professional’s most exciting task, keeping good records is good professional practice and makes sense. Good healthcare records protect patients, staff and you, now and in the future.

Keeping good healthcare records does not need to be an ordeal. Here are our top tips for taking the sting out of record-keeping.

Make sure you:

  • Keep content relevant. Notes on a healthcare record should include details of the patient’s relevant history, examinations, discussions with the patient, continuous observations, consultation with other professionals, treatment given, recommended treatment, care plans and risk assessments. Think about the information you would need to know if you just started your shift and had to treat the patient: this is what you need to record.
  • Present the notes well. Write your notes legibly. Always include the date and time of the note. This is particularly important when amending notes or making retrospective notes. Make sure to sign any entry you make on the notes.
  • Record notes in the same place. Make sure that healthcare records are recorded in the same place i.e. on a patient’s hard copy chart or electronic file. Do not record notes in log books or on pieces of paper which can be easily lost.

Do not:

  • use generic language or vague terms (e.g. “slept well”) unless they are specific to the patient’s issues / requirements;
  • criticise the patient or their family; or
  • record anything you cannot stand over.

In summary: stick to the facts!

 

Read the full briefing here.

 

 

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