The importance of patient care records

Providing the best patient care we can is always at the heart of everything we do as a service, and completing the patient care record for every patient is a vital part of this.

A patient care record (PCR) means we have an accurate log of the care we have provided, which we know helps us to give a comprehensive handover should we take the patient to hospital.  But, should something go wrong or if a patient dies unexpectedly, it also 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, better understand what happened and learning for the future.

Recently we carried out an audit of patient care record submissions  The good news is that we saw a 6.1% increase in the completion rate of patient care records from our last audit.  However, we still found that 12% of incidents had no patient care record and this is something we need to reduce – our target should always be 100%.

That means that every time we treat a patient over the phone or face to face, we must have a completed patient care record. Not completing one is unsafe for the patient, potentially puts you in a vulnerable position should the record be required at a future date, and it also goes against our legal duties and registration.

The audit showed some areas of excellent practice, and we’d like to give particular congratulations to south east Essex which scored 100% compliance. Well done and thank you.

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

Published 2nd March, 2017