SayPro Principles of record-keeping

The overall principles of record-keeping, whether you are writing by hand or making entries to electronic systems, can be summed up by saying that anything you write or enter must be honest, accurate and non-offensive and must not breach patient confidentiality. If you follow these four principles, your contribution to record-keeping will be valuable.

More specifically, you should always try to ensure that you:

• handwrite legibly and key-in competently to computer systems
• sign all your entries
• make sure your entries are dated and timed as close to the actual time of the events as possible
• record events accurately and clearly – remember that the patient/client may wish to see the record at some point, so make sure you write in language that he or she will understand
• focus on facts, not speculation
• avoid unnecessary abbreviations – as you’ll find, the health care system uses many abbreviations, but not all workplaces use the same definitions: for instance, ‘DNA’ means ‘deoxyribonucleic acid’ in some places, but ‘Did Not Attend’ (meaning a patient/client who does not show up for an appointment) in others – avoid abbreviations if you can!
• record how the patient/client is contributing to his or her care, and quote anything he or she has said that you think might be significant
• do not change or alter anything someone else has written, or change anything you have written previously; if you do need to amend something you have written, make sure you draw a clear line through it and sign and date the changes
• never write anything about a patient/client or colleague that is insulting or derogatory.
• When you’re writing, always follow the principles described in the section written communication and remember, if you find something you feel is significant when you are working with a patient/client, your first duty is to report it to the registered nurse in charge before you would consider writing it in the patient’s/client’s record. Always report first, record later.