Documentation of care is an essential part of ensuring that the care provided for patients/clients is safe, effective and person-centred.

This documentation may be in written or electronic form, and also be for use within your work setting or shared between different teams and agencies. Whatever the use, there are national, professional and local policies that you must understand and follow.

Documentation & confidentiality

As a registered member of the healthcare team, it is important that you uphold the standards your employer and professional body set regarding documentation and patient/client confidentiality.

The following resources will give you details of NHSScotland policy:

Ensure that you know, for example:

  • what constitutes patient/client identifiable information
  • your requirements under the Data Protection Act (1998)
  • policies for the use of patient/client information

Your professional regulator also has requirements in terms of patient/client confidentiality that you must adhere to.

Review your responsibilities as a registered healthcare practitioner.

You should use this information along with your local policies on information governance, which you should have been made aware on your induction programme.

However, if there are issues you are still unsure of discuss these with your mentor.

Record the key points and issues for your portfolio.

Reviewing your knowledge of record keeping

As a student you will have been exposed to various methods of documentation in the variety of healthcare settings that you worked in. This has provided you with baseline knowledge and experience in how to effectively document patient/client information.

Ask your mentor to orientate you to the local guidelines/policies regarding documenting patient/client care that you need to follow. It is vitally important that you fully understand the local patient /client documentation used in your work setting and your responsibility now that you are a registered practitioner.  

In discussion with your mentor, identify any learning needs that you have in relation to documenting patient/client care. Use the information you have reviewed in the Documentation and Confidentiality activity and what you have learned about the documentation in your work setting. For example you may need to learn about making referrals to other disciplines/departments or agencies, or about making concise and accurate entries in a patient's/client's records.  

Plan how you will meet these learning needs over the next 3 months. Remember to revisit this activity throughout the year as your experience increases.

Shared record keeping

You may be working in a team which uses shared record-keeping for patients/clients.  

Reflect on the challenges of ensuring shared records are secure, up to date and accurate:

  • where/how are the records stored?
  • who contributes to these records?
  • how is the information kept secure?
  • do all care providers who need this information have access to it and able to contribute?
  • how do you communicate with care providers who do not use these records?

Electronic communication

Communication and documentation using email is becoming more common in healthcare settings. Although emails tend to be less formal than traditional letter writing, you should ensure that you know your local policy on the use of email in healthcare settings.

Additionally, search The Good Practice Develop Yourself Toolkit in The Knowledge Network using the search term 'email' to access information about using email at work.  

You will need your Athens login to gain free access to these resources.

Reflect on what you have read and how you can change your practice in response to this. Add your reflections to your portfolio and return to them in 3 months to assess whether you have made these changes.

Electronic health records

Clinical staff members are being encouraged to record their patient/client information directly into e-Health Records rather than written records.

Explore examples of electronic recording of patient/client information within your team or work setting. Reflect on any challenges electronic recording presents either to you, personally, or the team you work in.

Documentation scenario

In your work setting, the team are using a multi-professional patient/client record which is kept at the patient/client's bedside. A family member/close friend who is involved in their care approaches you for advice about an entry within this record that they do not understand that relates to a change in the treatment plan.

  • how does policy influence how you deal with this situation?
  • how could you use the record in collaboration with the patient/client and the family member/close friend to help them understand the change?
  • how could communication be improved so that they do not find out about changes in care from the documentation?

Portfolio: documentation

You should now understand the policy, information governance and personal responsibilities for this most important aspect of patient care.

As a newly qualified practitioner, you may struggle to build your confidence in this area and to develop your knowledge of how and what to document and safeguard.  A good way to help develop your confidence is to ask your mentor or another registered healthcare professional for feedback on your documentation skills, both electronic and handwritten.

Having worked through a variety of the activities in this section, you should now summarise what you have learnt regarding confidentiality and patient/client documentation. Highlight how this will affect your future practice. You can share your findings with your mentor.

Add an alert to your Flying Start NHS® portfolio and /or make a date in your diary to revisit Documentation Skills.