Written Communication and Documentation Dr Sanjay Suri Consultant Paediatrician Rotherham General Hospital STEPP course 17 Oct 2014 Day 2

Outline Why write good medical records? Some do’s and don’ts Documentation in notes Communication with professional colleagues Electronic communication

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”

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

Objectives Audit and governance  Important in improving standards of care Getting paid  Clinical coding and Payment by Results  Quality indicators

Do’s Clear, accurate, legible, objective Contemporaneous First hand Relevant clinical findings Decisions made and reasoning Information given Treatment/therapy given

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

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

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

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

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

Dear Dr I saw this young lady in my clinic with varicose veins. On examination I felt an obvious thrill on tapping her vein into the thigh.I briefly explained the operation of stripping…..”

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

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

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

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