Documentation and Recordkeeping
The Documentation and Recordkeeping domain tests whether your records let someone else reconstruct what happened, when, by whom, and with what result. The exam favours contemporaneous, attributable, and complete records over neat-looking ones.
Record principles
Use the ALCOA+ ideas: attributable, legible, contemporaneous, original, accurate, complete, consistent, enduring, and available. Record the activity when it happens. Corrections should be a single line through the original, with your initials, date, and reason; never obliterate or overwrite. Explain blank fields and justify every N/A. Use unique identifiers and maintain chain of custody when items move. Keep version control for forms and procedures.
Worked example
After a shift you realise you forgot to record a required check. Do not backdate the entry to look contemporaneous. Make a late entry, mark it clearly as a late entry, give the actual time of the activity if it can be established from a reliable source, and record the time you are writing. Sign and date it. Then report the lapse through the correct channel.
Traps
- Pencil or erasable ink.
- Copy-forward entries that imply work not done.
- Pre-signing or signing for a colleague.
- Discarding raw data after entering a summary.
- Mixing units or omitting them.
- Storing screening images or personal data without authority.
- Using vague phrases such as 'checked OK' with no value or standard.