Appendix 3: NHO Standards for Content of the healthcare record

The following standards are only an extract from Part 2 of the NHO’s Code of Practice for Healthcare Records Management (2007) available here. We recommend reading the full document.

Standard 7

The content of the healthcare record shall provide an accurate chronology of events and all significant consultations, assessments, observations, decisions, interventions and outcomes. The content of each record shall comply with clinical guidance provided by professional bodies and legal guidance provided by the Clinical Indemnity Scheme. This standard shall apply to both hard copy and electronic documentation.

Rationale

The healthcare record and its content form an essential part of care allowing communication between healthcare professionals and demonstrating that the practitioner’s duty of care has been fulfilled.

Correct identification

6. The patient’s name shall be on each side of each page where patient information is documented and each page shall have the correct unique patient identification number and/or label. This shall also apply to every screen on computerised systems.

7. There shall be no blank spaces or pages between entries.

8. Before the healthcare professional makes an entry in the patient’s healthcare record, s/he shall establish that the record belongs to the patient being attended. This shall be done by verifying with the patient and by cross-referencing the patient’s wrist band with the healthcare record.

Legibility

9. All documentation shall be clear and legible.

10. When prescribing, writing shall be in un-joined lower case text or block capitals.

11. All entries shall be dated, timed and signed with a clear signature, printed name, title and bleep number (where relevant).

12. All entries shall be in permanent black ink.

Documenting date and time

13. It shall always be clear from the patient record the time that an event occurred and the time that a record was made.

14. The time (24-hour clock) and date (day/month/year) shall be noted against each clinical entry.

15. All entries shall be accurate in relation to date (day/month/year) and time.

Author identification

16. Each hospital site shall have an up-to-date signature bank of all clinical staff and non-clinical staff that may have occasion to write in the healthcare record.

17. Identification stamp pens, which have the clinician’s name printed on a stamp attached to the pen, shall be permissible.

18. All signatures shall be accompanied by a printed name. [...]

24. Records shall provide information on physical, psychological and social factors that may affect the patient.

25. The chronology of events and reasons for any decision made shall be recorded in the context of a thorough assessment of the patient including relevant history taking.

26. Records shall provide accurate, correct, comprehensive and concise information concerning the condition and care of the patient or client and associated observations.

27. Information shall be factual.

28. All entries in the record by healthcare professionals shall be made as soon as possible after each intervention and at least once every 24 hours during the working week for acute inpatient episodes. There shall be an entry in the record at least twice a week for rehabilitative care.

29. Every record entry (clinician related) shall identify the most senior clinician present at the time the entry was made.

30. The name of the primary clinician who is assuming overall responsibility for the patient’s care shall be clearly identifiable in the healthcare record at all times. The name in the patient’s record shall be the same clinician’s name entered into the Patient Administration System (PAS). Should the primary clinician change during the course of treatment, this shall be noted on the healthcare record and on the PAS.

31. Input into all records shall be multidisciplinary.

Retrospective entries

32. Retrospective documentation shall be:

• Dated.
• Timed.
• Signed (and counter-signed as appropriate).

33. The reason why the retrospective entry is being made shall be clearly stated.

34. It shall be clear that the entry is a retrospective entry.

Relevancy

40. Records shall be objective and shall describe what is observed.

41. If an incident has not been observed but is relevant to client care then this shall be clear, eg, patient states that...

Verbal instructions

42. Instructions regarding patient care from a healthcare professional via the telephone shall be documented, dated, signed and counter-signed by the healthcare professional responsible for giving the instructions.

43. If no instructions were given, this shall also be documented.

Abnormal results

44. There shall be a note in the clinical record of any significant abnormal results found or communicated to the healthcare professional. This shall include a record of who has been informed, eg, healthcare professional’s name. This note shall be made by the appropriate healthcare professional.

Medications

45. Drugs shall only be administered and documented in the presence of clear unambiguous prescriptions and in accordance with hospital policies.

46. Drug names shall never be abbreviated under any circumstances.

47. Generic names ONLY shall be used for the drug chart.

48. The choice of therapeutic agents used shall remain the responsibility of the clinician.

Language

49. Records shall be written in English.

50. Records shall be completed in terms that the patient and/or the healthcare professional can understand.

51. Records shall be supported by explanations where this may not be possible.

52. Records shall be phrased clearly and unambiguously.

53. Records shall be objective, factual, devoid of jargon, witticisms or derogatory remarks.

Advice

54. Healthcare professionals advice on care, in any format (eg, verbal, leaflet), shall be documented in notes of advice given.

Patient alerts and allergies

56. Alerts and allergies shall be recorded on the inside of the cover of the healthcare record chart.

57. The information shall be signed and dated and there is an end date for the alert, if appropriate.

58. The hospital shall have a clear procedure regarding who should enter alerts into the healthcare record, when alerts should be entered and the procedure for removing alerts from the healthcare record. These procedures shall be adhered to.

Admission entry

65. The following minimum, general patient information shall be included in the record entry for acute medical admissions and may also be supplemented with additional specialty information:

• Reason for clinical encounter.
• Presenting problem/complaint.
• History of presenting problem.
• Current diagnoses.
• Patient Alerts/Allergies (this should also be recorded on the inside of the front cover).
• Past illnesses.
• Procedures and investigations.
• Medications and diets including nutritional supplements.
• Social circumstances.
• Functional state (Self-care/baseline mobility/walking aids and appliances)
• Family history.
• Systems review.
• Examination findings.
• Results of investigations.
• Problem list.
• Overall assessment.
• Management plan.
• Intended outcomes.
• Information given to patient.

Follow-up entry

66. The following patient information shall be included in the follow-up entries for acute medical admissions:

• Reason for clinical encounter.
• Review of case.
• Overall assessment including any change since previous encounter.
• Management care plan.
• Information given to patient and carers.

Documenting consent in the healthcare record

72. Consent shall:

• Be easily and clearly identifiable either on a consent form, which is retained as part of the clinical record, or in the case of verbal consent, documented within the clinical record.
• Contain no abbreviations.
• Clearly state the procedure/treatment/care involved and the risks and benefits of that procedure.
• Clearly identify the patient by name and healthcare record number.
• Clearly identify who has granted or refused consent and/or their relationship to the patient in the case of parent/guardian.
• Have a documented record of what appropriate patient/client information or relevant discussions have been provided to the patient/guardian detailing the procedure/treatment/care, risks, benefits and/or alternative.
• Have a documented record of how this information has been provided (eg, patient/client information leaflets, verbally, etc).
• Be dated and signed by the healthcare professional obtaining the consent, including full name and grade.

73. Verbal consent shall be documented in the clinical record and shall clearly identify the witness, eg, by name and grade.

74. This standard shall apply to both hard copy and electronic documentation.