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 (see the next part of this section on Record-keeping), 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.
Fluid intake = 400mls/12hrs
(meaning not immediately clear)
Mr Smith drank 400mls during the shift
(message is clear)
Mr Smith returned to the unit with his
wife around lunchtime. (non-specific)
Mr Smith returned to the unit with
his wife at 11.45 am. (specific and accurate)
Mrs Brwn not vry appy tday but lkn frwd 2 her son vstng ltr (illegible, may not be understood)
Mrs Brown has not been very happy today
but is looking forward to her son visiting later.
(legible and easily understandable)
He did quite well at tea time, but I don’t think he
has eaten enough. (personal opinion)
Mr Smith managed to eat two-thirds of his evening meal but had refused lunch and afternoon tea. (reporting facts)
Mrs Jones was confused and was acting like
a drunk person. (judgemental, insulting)
When Mrs Jones answered the door, her speech was slurred, she was unsteady on her feet, and there was a distinctive smell on her breath, which may have been alcohol. (neutral, reporting facts)
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.