1. Good Documentation Practices

2. Introduction
The work done in Blood Transfusion centres affects the safety of donors, patients and staff and for this reason it is vital that documentation is of the highest standard. Written procedures must be followed, work done must be documented and records must be kept. The following Good Documentation Practices (GDPs) should be applied when performing daily duties across all departments.
DONOR
PATIENT

3. Good Documentation Practices
Contents
Evidence
Recording Information
Legibility
Blank Spaces
Correcting Errors
Date and Time Formats
Reporting Results
Deviations
Confidentiality
Falsification
Signatures
Meeting Timelines
Record Retention
Document Media
Good Documentation Practices

4. Evidence If it’s not documented, it didn’t happen!
Documentation provides proof or evidence that something was done
Record sufficient detail so that anyone looking at the document in future will know exactly what happened
Each document should be able to stand alone with all required information

5. Recording Information
Record information immediately
Don’t trust your memory because you may forget to record the information later
Don’t write results on loose pieces of paper as these may get lost
Don’t transcribe information from one form to another as this could lead to errors

6. Legibility All documents must be clear and legible
Information on a document is useless if it cannot be read and understood
Take care to write neatly and clearly
If your handwriting is not easy to read rather print in capital letters
Use black pen only, it photocopies well & is legal
Don’t write in pencil as this can be erased

7. Blank Spaces Don’t leave blank spaces on forms
Fill in N/A if not applicable
Or cross out section if not relevant
Otherwise it looks as though someone has forgotten to enter information
Do not use ditto marks as these could be taken for number 11

8. Correcting Errors Correct errors in a legible way
Draw a single line through mistakes
Write the correct information next to the error
Sign and date this
Anyone looking at the document should be able to see what information was changed and by whom
Do NOT try and write over the error as this makes it illegible or difficult to read
Do not ‘colour’ over mistakes, this makes documents messy and illegible
Never use correction fluid (eg. Tippex)
22 C 24 C Joe Bloggs 23/10/2015

9. Date and Time Formats Standardise date and time formats
Standardise and stipulate format for recording dates eg. dd/mm/yyyy
Ensure everyone records dates in same way
Check that dates on computer system match date format used on forms
Record times using 24 hour clock ie. 15:30 (not 3.30)

10. Reporting Results Standardise the reporting of test results
Report results to same number of decimal places as in specification
Labs to round off results as follows, when required:
- if number is below 5, round down
- if number is 5 and above, round up
Apply relevant correction factors for equipment to results before rounding off (as above)

11. Deviations If you deviate from procedure, record details
If anything out of the ordinary occurs make comments as to what happened
Months/years from now you may not remember the exact details so write them down
Document should be able to ‘tell all’ in future
Explain deviation and why it occurred
Remember to sign and date your comments

12. Confidentiality Confidentiality is crucial
Blood Transfusion centres must have a policy to ensure information relating to donors, patients or staff is kept confidential
This information may not be disclosed to any outside parties
Access to certain information should be restricted
Don’t share your PIN or password with anyone

13. Falsification Falsification must not be tolerated
Information entered on a form must be true and accurate
Results should be reviewed and checked by a second independent person, where possible
All errors should be corrected immediately
Action should be taken if staff are deliberately falsifying documents

14. Signatures Signatures must be traceable
One must always be able to determine who signed a document
Always sign your name in the same way
A signature list of all staff signatures (and initials) should be kept in each department
This list should be updated when staff leave or new employees join

15. Signature Fatigue Be aware of signature fatigue
In Blood Transfusion we sign lots of documents so take care not to become complacent
Double check any document before you add your signature
If something goes wrong and you end up in court you must be able to justify why you signed something and what your signature means
Joe Smith

16. Meeting Timelines Complete/ submit required documents on time
Procrastination causes problems for all
Don’t let paperwork pile up in your mailbox
Process documents promptly & get them off your back
Review and update SOPs when due
Complete internal audit reports on time
Process corrective action reports as quickly as possible

17. Record Retention Store records safely for stipulated periods
There must be a document stating how long records should be kept for according to the Standards/ legal requirements
Don’t store records for longer than required
Avoid duplication, don’t store documents if someone else is already keeping them
Document storage areas should be secure
Storage methods must prevent possible damage
One must be able to retrieve documents from storage in reasonable time if needed

18. Document Media GDPs apply to all types of document media
Includes paper/ hardcopy records with written data and a handwritten signature
Also includes electronic records which are completed on-line and signed electronically
Same applies to hybrid documents ie. electronic documents filled in on-line but then printed out for a written signature
With time more & more of our documents will become electronic. Hooray!

19. For the safety of staff, donors and patients: Do what you document and
document what you do !
Thank you