Are you reviewing your patient care records?

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Completing a patient care record (PCR) is part of the day-to-day working for many of us.

As well as being good practice, patient care records are considered important medical-legal documents, and are what we use to evidence what care and/or treatment we’ve delivered. They have to be completed and submitted for every clinical patient contact.

As part of our normal audit processes, and sometimes for more formal investigations, the clinical team often review both PCRs and ePCRs on a regular basis. It’s fair to say a good patient care record can give those reviewing them a really good idea of the assessment and rationale you have taken when treating, and making decisions for, your patients.

Some important points to remember

Firstly, please make sure you complete a PCR for every patient contact you make. That means you must keep records for everyone you treat or who asks for professional advice or services. There have been a number of cases recently where a case has gone to inquest and we’ve found that no PCR has been completed/submitted.

This makes it really difficult for those attending as witnesses to remember what took place, but also does not allow us to explain your actions well. The PCR is your record of what you’ve done – remember, if it’s not recorded, there’s no evidence of what you did and why.

Secondly, it’s really important that the most senior clinician on the resource, or at the incident, reviews the PCR before it’s completed. This is just to make sure that all the relevant information, including specific drugs administered and why, is recorded accurately. More information on this can be found in the patient care record policy.

A few tips

Wherever possible, our patient records should be: 

  • factual, consistent and accurate 
  • completed as soon as possible after an event has occurred, providing current information on the care and condition of the patient 
  • completed clearly, legibly and in a way that can’t be erased 
  • written in a way that any alterations or additions are dated, timed and signed, but ensuring the original entry can still be read clearly 
  • readable on any photocopies (for paper records) 
  • completed, wherever applicable, with the involvement of the patient or carer 
  • clear, unambiguous, and written in terms that the patient can understand.

Want to know more? Please feel free to contact the clinical team or read our patient record policy.

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