Clinical Records

Recording Changes in Accountability

Any change in clinical accountability should be recorded in the notes.

Care Plan Availability at Bedside

The care plan should be available at the bed and the reasons for any change in treatment should be recorded.

Recording Clinical Discussions

Clinical notes should always record discussions between clinicians and parents relating to patient care and between clinicians at handover or in respect of a change in care.

Record Keeping Audit

Record keeping should be subject to rigorous, routine and regular audit.