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Facing the consequences of poor record keeping and communication

09 February 2023
Volume 32 · Issue 3


John Tingle, Lecturer in Law, Birmingham Law School, University of Birmingham, discusses some publications on good practice in record keeping and communication and how failures can result in complaints and litigation

The objective of this column is to highlight several sources on good communication strategies, high-quality record keeping and so on. As well as informing readers' individual practice, I hope this will help those tasked with producing study days on the topic. I have tried to select a broad range of publications that present interesting and authoritative perspectives on the vexed issue of poor record keeping communication strategies – one that has plagued the NHS for years.

When you look back at the reports of adverse healthcare events, formal complaints and litigation, failures in communication seem to underpin many of them. If we improve our channels of communication there would undoubtedly be fewer complaints and less litigation. Poor communication strategies, including poor documentation, seems an easy acute patient safety issue to fix. There do not seem to be any major obstacles looming to stop improvement. In terms of fostering improvements, good record keeping and communication strategies should be seen much more as an intrinsic part of a nurse or doctors' individual professional skill set and duty. We should not be blandly accepting poor handwriting as a professional fact of life, as is seemingly the case in some quarters. If we confuse a number or figure it could mean that the wrong dose of a drug is given to a patient, with perhaps fatal consequences.

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