Contemporaneous notes
Information recorded about the patient should be written at the time of the event or as soon afterwards that is possible to provide a chronological and accurate record of events. This is vitally important as it captures the reality of the events within which the patient care was delivered and can be used in evidence in any legal proceedings. In Kent v Griffiths and others (2000) a challenge to the ambulance crew records resulted in the paramedics been found to have falsified their records to reflect that they responded to a patient call within nine minutes. Detailed examination of these and other records demonstrated that the time from call to arrival at the patient home had in fact been 30 minutes. Action against the paramedics then followed.
Similarly in 2002 a nurse was removed from the register by the NMC following a ruling by the Competence and Conduct Committee. The NMC (2002) found that the nurse had failed to keep adequate records on a patient relating to their diabetes, pain management and dietary needs and found her guilty of misconduct. It is important that advanced practitioners who will either treat patients independently or refer patients to other healthcare professionals ensure that contemporaneous notes are made at the time of the patient consultation and reflect the care given or omitted and the rationale for these decisions.
