Conquering Record-Keeping For Healthcare Professionals

Author:Ms Joanelle O'Cleirigh, Orla Keane and Roberta Guiry
Profession:Arthur Cox
 
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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!

FREQUENTLY ASKED QUESTIONS

Why do we need to keep records?

There are many reasons to keep good healthcare records, not least to safeguard the best interests of the patient:

Professional obligation: The Codes of Ethics of many professional regulatory bodies (e.g. the Medical Council, the Dental Council, the Nursing and Midwifery Board of Ireland) impose obligations on professionals to keep accurate and up to date records for all patients. Fitness to practise proceedings against professionals often involve allegations of a failure to maintain accurate or complete healthcare records. HIQA requirement: The Health Information and Quality Authority (HIQA) requires providers of healthcare services to have effective arrangements for the management of healthcare records. HIQA's National Standards for Safer Better Healthcare say that patients can expect that healthcare workers will record their information accurately and keep the records safe and up to date. Employer...

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