Standards for Recording Notes

Patient notes are legal documents and should be treated with care! Great Ormond Street hospital has drawn up the following standards that should really apply to all health care disciplines.

All entries into the health records must be written legibly and indelibly using permanent dark (preferably black/blue) ink. If an alteration must be made, the existing information should be crossed out using a single line;

All entries must be clearly dated. The time should also be noted in the case of emergency admissions and if multiple entries are made on the same day;

All entries must be in chronological order and signed by the author. The name and designation of the author must also be printed underneath for at least the first entry by them for a particular patient (i.e. TKhan [KHAN SHO bleep 7062]);

The notes should be kept in order with the minimum of a daily entry together with all unexpected or untoward events documented in full;

Only well recognised abbreviations and symbols (which are relevant to that specialty) to be used;

Details of verbal instructions or information given to patients should be recorded;

There should be no unnecessary personal or subjective comments about the patient and/or family;

All reports must have a patient name and number in full on them;

Remember to fill in the 'alert box' on relevant pages with allergy or sensitivity details;

All reports must be seen, evaluated and initialled by the responsible clinician before they are filed.