Completing patient care records

Every time we see a patient we must ensure we have a record of our attendance. 

Why is this important? Firstly, it enables us to accurately record our interaction with the patient so that we can ensure a comprehensive handover should we take the patient to hospital. But, should something go wrong, it means we can produce the record of our attendance showing exactly what we did; this means a coroner or investigator can review it, and help inform their decision making process and learning for the future.

Not completing a patient care record is unsafe for the patient, and potentially puts you in a vulnerable position should the record be required at a future date. On a more formal stance, it also goes against our legal duties and registration.

Every time you attend a patient you must:

• complete a PCR/ePCR (that adheres to documentation standards)
• submit the PCR as soon as is possible to the management team on stations, if completed on paper.

Remember, if you’d like to refresh yourself on what’s required, the policy for PCRs can be found on the Trust’s website.

Tracy Nicholls, Head of Clinical Quality, said: “We never plan for things to go wrong in clinical practice, but HCPC registration may be at risk and not having a PCR makes it almost impossible to support staff in times of a complaint, incident or claim, as we have no record of the decisions you made and why.  Please ensure you never put yourself in this position by completing good documentation for every patient contact”.

Published 24th November, 2016