Documentation and Communication
Documentation and Communication tests the record as a legal document and the spoken handover that transfers risk safely from one shift or facility to the next.
Core rules
- The clinical record is a legal document, admissible as evidence. Write at the time of the event, in ink, with date, time, signature, designation and employee number.
- Record objective findings (BP 150/95 mmHg, pulse 112/min) separately from subjective statements (patient says the pain is crushing). Use factual language, never opinion or blame.
- SOAP format: Subjective, Objective, Assessment, Plan. SBAR handover: Situation, Background, Assessment, Recommendation - used for both shift handover and calls to a doctor.
- Correct errors with a single line through the entry, write error and sign, then write the correct entry. Never use whitener, never overwrite, never tear out a page.
- Confidentiality is a duty; information is shared only with those involved in care or as required by law or the patient's consent.
- Communication barriers - language, hearing loss, pain, fear, sedation, jargon - must be reduced: use simple words, an interpreter where needed, and check understanding by asking the patient to repeat back.
Worked example
You realise you charted 40 mg of a drug when 20 mg was given. Reasoning: altering the record silently is falsification, while leaving it wrong is unsafe. The correct action is to draw one line through 40 mg, write error, sign and date, enter 20 mg, and inform the nurse-in-charge and prescriber so the patient can be monitored.
Traps that cost marks
- Using correction fluid or overwriting an entry.
- Charting a drug before giving it.
- Mixing opinion into an objective record.
- Discussing a patient's diagnosis in a public corridor.