Records, notes and handovers

Care records are legal documents, clinical tools and, one day, the answer to the question "what happened". They are also personal data that the person or their representatives may read. Write every entry as if the person and a coroner will both read it, because either might.

Accurate, factual, timely

• Accurate: record what actually happened, including times, quantities and names, and check you are writing in the right person's record before you start. Wrong-record entries are a common and serious error.
• Factual: describe what you saw and heard, not your opinions of the person. "Declined lunch, said he felt sick, ate a yoghurt at 14:00" is a record. "Being difficult again" is not, and it is exactly the sort of remark that causes hurt and complaints when families read the notes.
• Timely: write notes as soon as practical after the event, while details are fresh. If you must record something late, mark it clearly as a late entry with the actual date and time of both the event and the entry. Never backdate.

Mistakes happen. Correct them properly: strike through a paper error with a single line so the original stays legible, then add the correction, your name and the date. In electronic systems, use the amendment function. Never obliterate, delete or rewrite history.

Handovers

Handover is where care information does its most important work, and where it leaks most easily. Keep handovers in a private space, not a corridor or an open lounge where visitors and other people we support can hear. Share what the incoming shift needs to care safely, following need-to-know. And treat handover sheets as confidential documents: they are one of the most commonly lost items in care. They belong in the confidential waste or shredder at the end of the shift, not in a pocket that goes home, a car seat, or a general bin.