Defensible Documentation Policy

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Defensible Documentation Policy ...




    Date ratified by the PCT Board:

    Review date: Dec 2007

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    20 December 2005


    ENCLOSURE 4d Version History

    Version Date issued Issues To Brief Summary of Owner’s

    Change name V1.0 15 July 2005 Vicky Preece Rob

    Neill V1.1 27 July 2005 Vicky Preece Update following Rob

    comments from Neill

    Vicky Preece V1.2 21 Nov 2005 Vicky Preece, Update following Rob

    Kimara Sharpe comments from Neill

    Vicky Preece and

    Kimara Sharpe V1.3 2 Dec 2005 Rob


    Redditch and Bromsgrove PCT Crossgate House

    Crossgate Road

    Park Farm


    B98 7SN

    Date of Issue December 2005

    Location of document RB_pct\Information Governance\Defensible


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    1. INTRODUCTION ..................................................................................... 4

    2. POLICY STATEMENT ............................................................................. 4

    3. SCOPE OF THE POLICY ........................................................................ 4

    4. RESPONSIBILITIES ................................................................................ 5

    5. MONITORING/AUDITING ARRANGEMENTS ........................................ 6

    6. STANDARDS ........................................................................................... 6

    7. TRAINING .............................................................................................. 11

    8. REVIEW OF POLICY ............................................................................. 11

    9. SOURCE DOCUMENTATION ............................................................... 11

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    All health records maintained by Healthcare Professionals, are legal

    documents and must record accurate and complete information of a

    patient’s personal details, conditions, treatments prescribed, the

    outcome of their care and all follow-up contacts, not just those involving

    treatments thereafter.

    Failure to record information accurately in health records can have

    serious consequences for patients and their relatives. These failures

    may result in reduced quality of care and litigation. Poor record keeping

    is a major factor in litigation cases brought against Primary Care Trusts.

    This in turn hinders the defence of defensible cases.

    The quality of our records and communication with GPs and other

    colleagues is a direct measure of the service we are providing.

    Following the good practices laid down in this document will promote

    clear, concise and accurate health records.


    Redditch and Bromsgrove PCT will, for each patient treated, maintain a

    full legible and accurate record of the patient’s condition and care

    provided. This record will be audited for compliance with the specific

    requirements set out in this policy.


     This Policy applies to all directly employed Healthcare Professionals

    working for or behalf of the Redditch and Bromsgrove PCT: -

    ? All Nursing disciplines

    ? All Allied Health Professional disciplines

    Compliance with the requirements of the Policy is mandatory for all

    staff that record patient information. These individuals and their support

    team have a part to play in implementation of the policy.

    This policy applies to all written patient and electronic related

    documentation, not just hand written case notes.

    This policy should be used as a template, upon which other guidance

    can be built, as the standards it contains, should be adopted as a

    minimum requirement, unless approved otherwise.

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    4.1 The Chief Executive

    The Chief Executive has overall responsibility, on behalf of the Trust

    Board, for:

4.1.1 The application of the Policy and ensuring that the objectives of the

    Trust are achieved as safely, effectively and fairly as possible and in

    accordance with statutory requirements.

4.2 The Director of Nursing and Clinical services

    The Director has responsibility for:

4.2.1 The implementation and maintenance of the Policy

4.2.2 Ensuring that Managers co-ordinate and implement the Policy in their

    respective areas

4.2.3 Reviewing and amending this policy to ensure compliance with any

    current guidance

4.2.4 Monitoring, in conjunction with the Healthcare Governance Committee,

    the performance of the PCT and individual Services with regard to the

    implementation of this policy.

    4.3 Directors / Managers

    All Directors and Managers must:

4.3.1 Ensure that all staff are aware of the requirements of the Policy.

4.4 Employees

    Employees must ensure that they:

4.4.1 Comply with the requirements of this Policy

4.4.2 Report where applicable any deviances from the requirements of the

    Policy to their Line Manager.

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5.1 As part of the PCT’s ongoing Risk Management and Healthcare

    Governance arrangements, in compliance with CNST (Clinical

    Negligence Scheme for Trusts) standards, a periodic audit will be

    undertaken in all services as directed by the Director of Nursing and

    Clinical Services

5.2 The results of these audits, and any recommendations, action plans or

    improvements that have been made, will be discussed by the

    Healthcare Governance Committee

5.3.1 This group will be responsible for agreeing the action required to

    address any problems and for measuring the performance made

    against the action plan

5.3 Written evidence of the audit results and their appropriate action plans

    will be reported to the Healthcare Governance Committee. Areas of

    concern identified will be presented to the Healthcare Governance

    Committee, who may require the production of detailed action plans to

    minimise any potential risk.


6.1 Basic principles of documentation

    ? All patient records must be legible

    ? Records must be written so that they are capable of being

    photocopied (usually black ink)

    ? Correction fluid (e.g. Tippex) must not be used in patient records

    ? All errors should have a single line drawn through them, be initialled,

    dated and timed, so that the error can still be read

    ? All entries should be in chronological order with no spaces between


    ? Do not squeeze in extra words on a line

    ? Draw a line through any empty space at the end of an entry

    ? Ditto marks should not be used

    ? The use of glue is not permitted due to problems with glue


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? No papers should be removed from the clinical file, other than for the

    purposes of photocopying following which they should be returned

    and filed immediately

? Each page of the documentation should be sequentially numbered

    where possible. However, where documentation is kept in separate

    sections, then they should be clearly consecutive.

    6.2 What should be documented in the clinical record?

    6.2.1 Clinical content

? The clinical record should provide a detailed account of the patient’s

    condition and care. This should begin from the moment a patient

    accesses PCT services to the moment that they leave them

? The patient’s name and ID number should be entered on to each

    page (date of birth should be used if ID number is not available).

    The use of department identifiers, which match the full name and

    professional designation on a department register of staff, is also an

    acceptable practice.

    NB. It is planned that by December 2007 that the patient’s ID

    number will be their NHS number

? Each entry or significant event should be dated and timed. On the

    first entry the writer’s name should be clearly printed accompanied

    by their signature and professional designation

? Each patient’s record should give a full, legible and understandable

    history and full assessment including positive and negative findings.

    It should provide an accurate and detailed account of significant

    events which fall into the following headings: -

    ? Patient assessments, patient intervention and patient outcomes

    ? Initial and ongoing assessments by each health care provider,

     including social history

    ? Patient’s condition on admission to hospital or caseload or


    ? Patient’s statements regarding signs, symptoms and history of


? Legible instructions for all treatment, therapies and medications

? Records should be factual, consistent and accurate

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? It is permissible, and in some cases even advisable, that where a

    decision on management is made that is at variance with usual

    clinical practice, for the health professional making this decision to

    clearly document the thought process leading to that decision

? Professional bodies do not recommend the use of abbreviations

    and they should therefore not used unless absolutely necessary. In

    the case where abbreviations have to be used then they should be

    written out in full the first time that they are used

? Jargon, meaningless phrases, irrelevant speculation and offensive

    subjective statements are not allowed

? Records should be written, wherever possible with the involvement

    of the patient, client, or their carer they should be written in terms

    that they can understand, be consecutive and identify problems that

    have arisen and the action taken to rectify them

? They should provide clear evidence of the care planned, the

    decisions made, the care delivered and the information shared

? Details of instructions relating to:

    i) Do not resuscitate orders

    ii) Advanced directives

    iii) Living wills

    Should be located in the patient’s records where it is clearly

    visible, ensuring that all health professionals are aware of the

    patients wishes

? Where written consent is required the form must be completed and

    then signed by the patient and health professional. Once this has

    been done one copy should be filed in the patient’s notes and one

    copy given to the patient in accordance with the PCT Consent


? As required by the CNST standards, where appropriate operation

    notes and other key procedures that have been entered in to the

    documentation should be readily identifiable from other entries. The

    gluing of these notes in to the record is not permitted due to

    problems with glue deterioration

? Prescribed medication doses given and omitted showing route,

    amount, time administered and signature of person who has

    administered the dose, in accordance with the Medicines Code


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? Health education provided to the patient or family should be

    documented, including instruction on care, medications, treatments,

    dietary requirements and referral information

? A record of communication / discussion with a Doctor/GP or a

    record of any attempted contact with a Doctor/GP.

    6.2.3 Discharge

? Discharge / transfer of care instructions and information given to

    patient, relatives/carers, and other health professionals should be


? The preliminary discharge letter must be legible and complete. The

    preliminary discharge letter should be written and sent within 24

    hours of the patient’s discharge and a copy inserted into the notes

? The full discharge summary/report should be sent to the referring

    agency within 14 days of discharge. This discharge summary/report

    should give the principle diagnosis, any subsidiary diagnoses,

    and/or any surgical operations and procedures and a copy kept in

    the notes

? It should also include all discharge medication; indicate follow-up

    arrangements and any information given to patients and/or relatives

? Where discharge from the care of the service is not routinely

    followed up with a discharge letter then discharge should be noted

    in the patient’s documentation

    6.2.4 Patient protection

? In the event of an incident, full details must be reported in

    accordance with the PCT Incident Reporting Policy and (if

    necessary) Serious Untoward Incident Policy

? A patient’s refusal to co-operate or follow a prescribed plan of care,

    including leaving hospital against medical advice, should be

    documented and witnessed by another member of staff in the case

    notes. Staff should endeavour to get the patient to sign a self-

    discharge form, a copy of which should be stored in their case notes

? Staff from all agencies, departments and specialties must ensure

    that a record of any discussion on a patient that has been held

    outside of normal working hours (at home or elsewhere) is recorded

    in the patient documentation. The entry in the notes should clearly

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    state details of the timing and location of the communication, and

    that it is clear that the entry is being made retrospectively.

    6.2.5 Administration For Hospital Patients

? An alert label should be affixed to the front of case notes

    indicating patients with similar names

? For minor surgery procedures e.g. in podiatry clinics, notes

    should be typed where possible and filed with the relevant history

    sheets. Glue must not be used

? For in-patients, valuables handed in for safekeeping must be

    documented in accordance with local procedure

    ? All documents must be securely fastened in the case notes in the

    correct filing format on patient discharge. For medical case notes

    guidance on the correct filing order is found on the inside of the

    back cover. When the case notes are transferred to another ward

    or hospital, laboratory, x-ray and other diagnostic/therapeutic test

    results must be secured appropriately within patient notes by the

    member of staff organising the discharge/transfer of the patient. Community Services

? All health professionals should follow the PCT Records

    Management Policy for filing and storage of patient records.

    6.2.6 Child protection

? In instances where non-accidental injury to a child is suspected, the

    reasons for these suspicions should be noted in the patient

    documentation. The actions that have been taken, or that are

    planned, should also be entered

    ? Where the patient is of school age the details of the child’s school

    should be entered in the patient documentation. If these details

    already exist in the documentation then they should be checked to

    ensure that the information is still correct. NB In those instances

    where the information of the patient’s school is not given or known,

    it should be passed to the named nurse for child protection, who will

    ensure that the relevant child health worker is notified of this

? All agencies, departments and specialties must ensure that e-mail

    communication about a patient is printed in hard copy, signed and

    then placed with the relevant case file or patient documentation

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