July 2013

AHP Clinical Notes Checklist

Entries should be written at the time, or as near to the time of the event as possible, and not latter than 24 hours after the event
Black ink
Legible writing
Signature, name printed, designation, initials and date completed in front of notes on the occasion of making first entry to the notes
Date of entry in first margin
Time of entry in second margin
Time the person was seen between/how long they were seen
Where they were seen
Any names of anyone else present
The entry should be of clinical significance
Enter what you did
What you sawand heard,
Include any assessments you have done and direct to where they will be found for further information
Include any assumptions, inferences or conclusions you drew from this contact
Use your entry asa means of communication to ensure continuity of care
Signed in end margin
Errors to be crossed out with single line and initialled - no correction fluid
When entry is completed draw a single line to the end margin to ensure nothing else can be added under your entry
If there are blank spaces in the notes cross through with a single line if a short space, or a 'z' if a larger area
If using abbreviations only use those recognised and accepted in the Trust, as per listed in the back of the medical notes
Don't leave blank spaces in forms, these should be stated as not applicable and signed
Tick boxes should be initialled to indicate who completed them
Ensure your entry is of quality standards not quantity
Ensure your entry is in a chronological order
Ensure RRE/NHS numbers are on relevant documentation
Ensure there is no Jargon or meaningless phrases
Ensure records are safe and secure
Ensure the records are absent of plastic wallets
Ensure all information within the records is secure and there are no loose documents
Never return to your records at a later date to improve them

AHP Clinical Notes Standards

  • Failure of governance is a failure of professional conduct. Each professional is personally answerable and can be called to account for what they did or did not do, said or did not say.
  • If you didn't do it, see it or hear it, it is not a fact, so then you are drawing an assessment, inference or assumption, so be clear that is an assessment, assumption or inference not a fact, but that it is based on what you saw, what the service user / you did and what you heard
  • You can use the word appears, but use it carefully i.e. if it is a fact e.g. someone's arm is bleeding, or you heard them say 'I feel tired' state it is as this not that it appeared to be bleeding, or the person appeared tired. If you saw the person yawning and their eyes kept closing you can state this is what you saw and then say based on this they appeared tired.
  • Avoid ambiguity e.g. ambiguous - no problem identified. Be clearer e.g. no problems reported when asked.
  • Make sure not making a diagnosis e.g. service user is depressed, can say service user reported they feel depressed, or service user had limited eye contacted, did not engage in conversation, declined to have a drink, was tearfulhence appeared low in mood.
  • Third party information should be stated as this e.g. phone calls from relatives, and clearly marked as confidential if they do not want this information disclosing to the service user.
  • If you need to amend an entry to add something you forgot a new entry clearly indicating this should be made.
  • If you are in a meeting and it is documented that a team decision is made, but you are not agreement with this, you should make sure this is accurately recorded.
  • Your notes should facilitate care and ensure colleagues can use your notes to continue care without any verbal additions.
  • When you make your entry have the reader in mind – what information do you want them to take away?
  • Diaries, message books, travel claims, emails and text messages can be used as evidence in court.
  • Write only fact – what you saw, did or heard.
  • Opinions or decisions should be objective and based on the facts.
  • Back up any assumptions with facts that support such as “during the visit there was no eye contact, a lack of conversation and they reported they had a lack of appetite therefore appears low in mood”.
  • Useful to quote verbatim “I’m depressed today”.
  • Good record keeping should support evidence-based clinical practice
  • Good record keeping should support patient choice and control over treatment and service designed around patients.
  • Ensure you record any information given to the service user/carer including information given before consent is given.
  • Record details of any follow up arrangements such as future plan of care or future appointments.

*This checklist and standards have been developed with legal guidance from Bond Solon Legal Training Consultancy and South Staffordshire and Shropshire Healthcare NHS Foundation Trusts policies.