Posted on Monday, 13 December 2010 8:10 a.m.
Good report writing is important.
Progress notes, incident, accidents and infection control reports all become part of resident’s file. These records are saved for 10 years after the person passes away. The writer of these entries can be questioned about their report years after the event and if the report is not clear nobody would be able to recall an event so many years later if the report is not written in a factual, objective manner.
I have read reports where I could gather exactly how the writer felt at that moment because all I read is the emotion of the writer. The writer wasn’t able to give clear facts about the event when asked a couple of months later.
It is a very worthwhile training session to have with staff on a regular basis. Good report writing takes training and practise, taking in account that a lot of staff have English as a second language.
Reports should state what the writer could see, hear, feel, smell, and touch, without giving judgment.
Writing: “John was angry and aggressive this morning” does not mean a lot or can be interpreted in different ways by different people.
Writing: “John walked up and down the corridor waving his walking stick calling out that he was going to hit Mike for taking his book”. Any person reading this, even years later, will know what happened and the people involved.
All entries need to have a date noted and there should be a way of establishing a timeline. If your policy states that progress report are written an hour before each shift finishes you have established a time line. In that case your progress notes have date and am, pm of night written in front of the entry. If the exact time is important to explain the event then it is also documented in the progress notes.
It is good practice to write the date and the time in front of the entry.
All exception reports (incident/accident etc) have the exact time noted as this is important for investigations.
Ensure all entries are signed and designation of writer noted.
There should be a signature verification log so that initials and signatures can be verified.
I am sure the following is not new for anybody but it is worth repeating:
“If it is not written down it didn’t happen!!”
My favourite: “if it is not written down good it is not worth writing down!