Record Keeping

Record Keeping

Good records are essential to safe and effective patient care and should be:

  • Clear, legible and indelible
  • Factual and accurate
  • Written as soon after the event as possible
  • Signed, timed and dated
  • Be written with the involvement of the patient, client or their carer
  • Be written in terms the patient or client can understand
  • Be consecutive
  • Identify problems that have arisen and action taken to rectify them
  • Show care planned, decisions made, care delivered and information taken

Please bear in mind that full records are essential should any questions be raised about the care and standards of care delivered.