Written Communication and Documentation

1. Written Communication and Documentation STEPP 8/09/2011 Consultant Paediatrician Rotherham General Hospital

2. Outline Importance of good medical records Some do’s and don’ts Documentation in notes Communication with professional colleagues Electronic communication

3. Why are good medical records important? GMC- Good Medical Practice 2001 Doctors should keep “clear, accurate, legible & contemporaneous records, which report the relevant findings, the decisions made, the information given to patients and any drugs or other treatment prescribed” “keep colleagues well informed when sharing the care of patients”

4. Objectives • To assist teamworking • Promote continuity of care • Keep colleagues well informed • Ensure patient safety • Complaints and claims • Notes may be the only defence • Many claims are indefensible because of poor documentation

5. Objectives • Audit and governance • Important in improving standards of care • Getting paid • Clinical coding and Payment by Results • Quality indicators- bonus funding awarded

6. Do’s Clear, accurate, legible, objective First hand Decisions made and reasoning Treatment/therapy given

7. Do’s Date and time each entry Write in black permanent ink Any changes/alterations should be added as new entry, reason for change, signed and dated/timed Always print and sign full name Grade and bleep

8. Don’ts Not too long/short Cross out and overwrite Use blue or other colour pens Use ink pens Do not change/tamper records Do not add information to previous entry- new entry but state written in retrospect

9. Communication with professionals GP referrals to hospitals Referrals to other professional colleagues Clinic letter to GPs and other professionals Information sharing with other agencies Discharge summaries

10. Discharge summaries Dictated/written same day Time lag between dictation and typing Time lag between typing and signature RCPCH recommends 10 days target for letters to GPs GPs value feedback without delay Avoid “?” or “possible” diagnoses

11. Content of letters Diagnosis/problem list Relevant examination findings Investigation results Treatment/proposed management plan Current medication list including side effects Information given to patients Psychosocial concerns

12. Copy letters to patients/parents Improve parent/patient satisfaction Improve compliance Potential to increase parent anxiety Concerns over use of medical jargon

13. Electronic communication Being used increasingly Computer generated discharges- time saving and efficient Electronic booking system E mail- must be secure, eg, nhs.net if using patient identifiable information

14. Patient confidentiality and safety Caldicott guardians: responsible for overseeing access to and storage of patient-identifiable information Keep records safe and access to records should be restricted

15. Summary • Documentation • Clear and concise • Indelible ink, legible • Accurate • Contemporaneous where possible • Dated and timed • Signed in full, grade and bleep