Health services need to keep good written records of the care given to patients/clients for three main reasons:
- To make sure the care and treatment can continue to be given safely no matter which staff are on duty, 24 hours a day, seven days a week
- To record the care that has been given to the patient/client
- To make sure there is an accurate record to be used as ‘evidence’ when there is a complaint from a patient/client about the care they have received.
You’ll be supporting registered staff to prepare and update patient records, so having a sound grasp of the principles of written communication is important. The actual level of your involvement in written patient records will vary from workplace to workplace – you need to find out what’s expected of you in your workplace and make sure you follow the rules.
You’ll be supporting registered staff to prepare and update patient records (see the next part of this section on Record-keeping).
The principles of written communication are that you should:
- Write as near as possible to the time you’ve delivered the care
- Write simply and clearly
- Write legibly (if hand-written) and as error-free as possible if keyed into a computer
- Insert dates and times as accurately as possible when specific events and circumstances occurred
- Avoid giving personal opinions
- Avoid writing anything judgemental or which may seem personally abusive or insulting. Report factually what you have observed.
And remember, as part of the health care team, you have a responsibility to make sure that anything you write about a patient/client (or that any other member of staff writes, for that matter) remains confidential and cannot be accessed by any unauthorised person. We have already considered this vital issue in confidentiality.