Documentation: are we writing it right?

How many times has the phrase, ‘If it's not in the medical record, it didn’t happen’ been used during court cases reviewing documentation by healthcare professionals? With this phrase, there has been an ever increasing emphasis on good record keeping among all healthcare professionals, and indeed this has become an ever increasing maxim for paramedic practice.

While the need to keep accurate patient records is acknowledged by the bodies that govern healthcare practice, including the Health and Care Professions Council (HCPC); the General Medical Council (GMC) and the Nursing and Midwifery Council (NMC), there is currently little evidence to support a specific standard of record keeping, with advice on following one of several recognised models. For many ambulance Trusts, documentation guidelines are based on expert opinion of what should constitute good medical records and documentation, but this can vary from region to region. However, whichever model is used, there are several core principles that should be used when writing medical documentation.