Documentation: key things to consider when writing in patients’ records

Documentation word cloud

When you document in patient notes it’s important you keep things clear and accurate; they should be an honest and timely objective record. Avoid personal language and subjective commentary, the notes should be appropriate and non-discriminatory. Remember it’s a legal and professional document and bear in mind that your patient might read them one day.

It may seem daunting at first and your approach or documentation style may vary between different placement areas but hopefully these tips may help you understand what is expected when you’re asked to document your shift and make sure you check the documentation and records keeping policy at the trust you are based at.

dr handwriting

Ensure you keep your handwriting legible if writing handwritten notes! If you’re typing up electronic records make sure you have spelt everything correctly, beware of any spellcheck programs that may auto-correct any medical terminology they do not recognise.

Electronic records systems will automatically produce a time stamp and will record the name of the person logged in as the author of that note. If you’re handwriting notes you will need to do this by hand and include the date and time for each entry and end with your name, designation and signature. If you need to add anything, add this on a line below and sign next to it. If you need to add or amend any computerised notes, some programs will allow you to log back in and edit the record within a certain time frame of the entry. If not, just simply add a new entry detailing the addition or amendment you want to include.

If you’re editing any paper documentation remember not to use tippex, just use a single line to strike through the text and sign next to it. It’s also good practice to use a line to strike through any blank space on a line at the end of a sentence so nothing can be added in later. You’ll need to make sure your mentor or the registered nurse working with you on that shift also countersigns your documentation.

abbreviations

Although your handover sheet is probably littered with abbreviations like a secret code, it’s best to avoid them when you’re writing up notes unless they are from an approved list. The meaning of some abbreviations may vary between trusts or specialities and may cause confusion if the meaning isn’t clear!

In terms of format and content, it’s really up to you!  Some people prefer to write up the shift chronologically whereas others use an A-E based format or to divide content by body system. For more tips and ideas have a look at Heather’s post here on writing in patient notes.

You may also wish to include any patient contributions to their own care or any significant remarks from them during the shift if relevant. If you do feel that something is significant, for example if a patient has a concern or if you notice a deterioration in their observations or anything else worrying you, make sure you escalate it by reporting things to your mentor or the nurse you are working with first, then you can record it afterwards.

You can find some other resources on documentation here:

 

 

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