Documentation: are we writing it right?

Abstract

Abstract published with permission. While the need to keep accurate patient records is acknowledged by the bodies that govern healthcare practice, 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. This article aims to provide ambulance staff with general information on documentation in an attempt to enable readers to understand why records are kept, the standard to which records should be kept, and the legal and regulatory issues relating to record-keeping for paramedics.