Welcome to episode 34 of Continuous Quality Compliance

Today I am talking about Report Writing

Before you start writing consider....

WHO are you writing the careplan, treatment record for?

WHY are you writing it?

HOW do you record it?

What is written needs to be factual and correct. It also needs to meet the needs of different stakeholders.

Steer away from a tick box culture as this will not provide enough information .

What you record can be broken into 4 areas;

Times, places, people involved, events happenings /consultation

Good reports should be legible, in simple language jargon free as possible. Clear factual, accurate. /in chronological order, enough information

A good way to train staff on good report writing is to have a sample of a good report and one of a badly written one.

If you’re a medical professional registered with the GMC, NMC , HCPC they have standards for record keeping which should also be looked at and be part of the organisations policy o record keeping.

If it is not documented it has not been done.

Common problems are:

An absence of clarity

Inaccuracies

Spelling mistakes

Missing information

Failure to record action taken when a problem has been identified.

Good Record Keeping

Record keeping makes the continuity of care easier;

Record keeping promotes better communication and dissemination of information between members of the multi-professional team;

Helps to address complaints or legal processes;

Supports clinical audit, research, allocation of resources and performance planning;

Helps to identify risks and enables the early detection of complications;

Supports client care and communication;

Supports effective clinical judgement;

Supports delivery of services;

Helps improve accountability;

Shows how decisions were made relating to the patient’s care.

What I ask is when your are writing would you be happy for what you have written to be read in a court of law? Also read it out a loud you will see if what you have written does not sound right.

Good record keeping is also important as part of being a member of a professional body.

Reference: NMc, GMc Ausmed , HCPC

http://www.tchauhanconsultancy.co.uk/ (www.tchauhanconsultancy.co.uk)