Communication, Documentation, and Information Governance
Communication
MDT communication includes the meeting, the written output, and communication with the patient, carers, and other agencies. Use closed-loop communication for actions: state the task, the owner, and the deadline, and have it read back. Confirm that the patient understands the plan in the way that suits them.
Documentation
Records should be contemporaneous, legible, attributable, and factual. Separate observation from opinion; record who said what where disagreement matters. The MDT output should include the decision, the rationale, the plan with named owners, and the review date. Avoid 'team agreed' unless you record what was agreed.
Information governance
Apply lawful basis, necessity, and proportionality. Share only what the recipient needs; confirm identity and secure route; record consent or the legal basis for sharing without it. The Caldicott principles are a useful checklist: justify the purpose, use the minimum necessary, access on a need-to-know basis, understand and comply with the law, and keep it secure.
Traps
Recording hearsay as fact; including third-party sensitive information without need; using personal devices or unsecured email; assuming consent to treat equals consent to share; and action logs with no owner or date.
Worked example
A carer asks for the full case note. Clarify what information is needed and why, check the patient's consent or other legal basis, share the minimum relevant information securely, and record the disclosure.
Rule of thumb
Write as though the patient will read it and a court will too. If you would not say it to the patient, do not write it.