Notekeeping

It is impossible to record everything that happens in intensive care in the patient's notes. The 24h observation chart provides the most detailed record of what has happened but summary notes are essential. Such notes must be factual without unsubstantiated opinions about the patient or about previous treatment. All entries must be timed and signed. Records of ward rounds must record the name of the consultant leading the round. It must be remembered that the notes may be used later in legal proceedings. They may be used against you but, if well kept, will usually form the best defence. In the event of a medical mishap the episode should be clearly documented after witnessed explanation to relatives.

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