In this article, Natasha Coen and Mary Godfrey from the SCA’s Clinical Risk Unit outline the issues with recording and documentation in the Healthcare Record (HCR) and provide advice for safe practice.

Falling short of the required standards for documentation practice within the HCR can have serious consequences for the care provided to the service user. This may result in the disruption of continuity of care, incorrect decisions regarding treatment, unnecessary diagnostic tests being performed or wrong site surgery.

Examples of documentation-related incidents reported on the National Incident Management System (NIMS) include failure to record clinical details and clinical findings, absence of the results of diagnostic investigations, absence of patient records during transfer of care, absence of discharge letters and failure to document care plans and follow-up arrangements.

To reduce the risk of adverse effects to service users, health and social care professionals should undertake documentation practice in accordance with national policy and standards, as well as legal, regulatory, and professional requirements.

Risk Factors

A number of risk factors have been identified which contribute to shortfalls in the required standards for recording and documentation in the HCR which include:

• Not documenting notes during, or immediately after, an interaction with the service user, resulting in reliance on memory, which can lead to omission of relevant information
• Lack of a standardised process for documentation relating to discharge and follow-up arrangements
• Illegible hand-writing or misunderstood dictation
• Transcriptional errors e.g. “hypo-” instead of “hyper- ”
• Use of abbreviations in the HCR that have not been agreed and approved
• Incorrect selection from pick list options within electronic healthcare records
• Misuse of “copy and paste” functions in electronic healthcare records
• Use of multiple electronic systems that are not integrated, resulting in missed episodes of care
• Failure to undertake frequent audit of documentation within HCRs
• Insufficient education and training for all health and social care professionals on documentation practices

How to minimise the risks

• Practise in accordance with national policy, standards and professional guidance
• Ensure notes are contemporaneous by allowing sufficient time to document while with, or immediately after, interaction with the service user
• Use a standardised approach/process for documentation at transitions of care e.g. transfer of care between practice settings and discharge
• Use approved abbreviations only
• Document discussions relating to risks, benefits and alternatives of treatment and any advice provided
• Audit the documentation processes to ensure practice complies with national policy, standards, and professional guidance
• Provide appropriate education and training on documentation and recording practices for all health and social care professionals
• Implement an Electronic Healthcare Record system, where possible
• Ensure electronic service user information platforms are compatible and integrated, where possible

References available on request